Please enable JavaScript.
Coggle requires JavaScript to display documents.
Rheumatoid Arthritis - Coggle Diagram
Rheumatoid Arthritis
Biologic agents
in patients resistant to DMARD
inhibit activity of TNFalpha which mediates inflammation in RA
used with methotrexate or leflunomide
Caution : infections (TB, septicaemia, Hep B reactivation)
Before treatment, screen for infections : TB and hep B
Side effects : Predisposition to infection, nausea, abdominal pain, worsening of heart failure, hypersensitivity reactions, fever, headache, depression, antibody formation, pruritus, injection site reaction, blood disorders
Patient monitoring : infections, heart failure, hypersensitivity reactions
Anakinra
interleukin-1 receptor antagonist
Side effects : severe infections & neutropenia
Monitor : CBC
Abatacept
prevent full activation of T lymphocytes
used with methotrexate, should not be used in patients receiving TNF inhibitors
increases predisposition to infection, cause blood dyscrasias
side effects : abdominal pain, diarrhoea, dyspepsia, nausea, flushing, hypertension, cough, dizziness, fatigue, headache, infection, rhinitis, rash
Drug Therapy
NSAIDs
Steroids
DMARDs - disease modifying antirheumatic drugs
antimalarials : hydroxychloroquine
400mg in divided doses, maintenance of 200-400mg daily to be taken with or after food
Side effects : GI disturbances, headache, skin reactions, ECG changes, visual disturbances, convulsions, blood disorders
Monitor : RFT, LFT, visual acuity, FBC, ECG
immunosuppressants : methotrexate, leflunomide, sulfasalazine
biologic agents : infliximab, adalimunab
Gold (Sodium aurothiomalate)
orally
10mg IM test dose, then 50mg weekly, then reduce dose
Side effects : GI disturbances, stomatitis, diarrhoea, rashes, marrow suppression, proteinuria
Monitor : CBC, urinalysis before each dose, CXR
Clinical presentation
Fatigue, weakness, swelling of soft tissues around joints
Stiffness & muscle aches
morning stiffness
symmetrical joint involvement
Haematological tests : Anaemia, thrombocytosis, increased ESR, increased CRP, rheumatoid factor positive
Goals of Treatment
relieve symptoms of pain, swelling, stiffness
preserve joint function
prevent further disease progression
improve quality of life of patient
deal with extra-articular manifestations
NSAIDs
supplement DMARDs & maintain patient as symptom free as possible
COX-2 selective
celecoxib
Partially selective NSAIDs
meloxicam
7.5-15mg in 1 dose
Non-selective NSAIDs
Ibuprofen
1.2-2.4g in 3-4doses
Naproxen
500-1000mg in 2 doses
Ketoprofen
100-200mg in 2-4 doses
DMARDs
Methotrexate
moderate-to-severe disease
action within 4-6wks
single weekly oral dose
SC or IM
5-25mg once weekly
Avoid alcohol intake - reduce risk of hepatic fibrosis & liver toxicity
Monitor liver function, CBC, renal function
Add folic acid dose once weekly - manage nausea & stomatitis
side effects : Rashes, nausea, stomatitis, marrow suppression, hepatitis, pneumonia
do not take aspirin or NSAIDs on same day - reduce methotrexate elimination = increased toxicity
Teratogenic
Leflunomide
side effects : GI disturbances, headache, hypertension, alopecia, rash, bone marrow toxicity, rarely potentially life-threatening, hepatotoxicity, increased risk of malignancy
Cautions : Renal & hepatic impairment
Contra-indications : History of TB, impaired bone marrow function
monitor : LFT, CBC, BP, signs of thrombocytopenia & neutropenia
teratogenic
active metabolite with long half-life
Sulfasalazine
500mg once daily, increased to 1g 3times daily
Side effects : Nausea, reversible male infertility, rashes, bone marrow, suppression, hepatitis
Monitor : CBC, LFT, renal function test & electrolytes
Ciclosporin
2.5mg/kg per day in 2 divided doses
Side effects : hirsutism, gingival hyperplasia, hypertension, renal impairment
Monitoring : Every 15days : U&Es, BP, urinalysis then 1-2 monthly
Azathioprine
1.5-2.5mg/kg per day
Side effects : GI disturbances, diarrhoea, marrow suppression
Monitor : Every 15 days for 2-3 months : CBC, U&Es, LFT and then 1-2 monthly
corticosteroids
rapid anti-inflammatory response
monitor bone mineral density, use calcium supplements & prophylactic therapy for osteoporosis
prednisolone
temporary relief during flare up
bridge therapy until DMARD is effective
divided dose not single dose in morning