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How often should RA treatment be adjusted until target is achieved?
How often should RA treatment be adjusted until target is achieved?
When it comes to RA, early diagnosis and aggressive treatment reduce disease progression and prevent joint damage, which accumulates over time
When it comes to RA, early diagnosis and aggressive treatment reduce disease progression and prevent joint damage, which accumulates over time
True
What is the preferred initial monotherapy for patients with RA that should be started within 3 months?
What is the preferred initial monotherapy for patients with RA that should be started within 3 months?
A patient with moderate to high disease activity (diagnosed less than 3 months ago) cannot take methotrexate. What can you use instead for this patient with early RA?
A patient with moderate to high disease activity (diagnosed less than 3 months ago) cannot take methotrexate. What can you use instead for this patient with early RA?
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What is the best choice medication to start in a patient with low activity disease?
What is the best choice medication to start in a patient with low activity disease?
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What is the recommendation for additional therapy when a patient is on DMARD monotherapy (such as MTX) but still needing more relief?
What is the recommendation for additional therapy when a patient is on DMARD monotherapy (such as MTX) but still needing more relief?
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What are contraindications for Methotrexate?
What are contraindications for Methotrexate?
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What medication should be started with Methotrexate?
What medication should be started with Methotrexate?
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You should get a chest XR before starting Methotrexate
You should get a chest XR before starting Methotrexate
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What csDMARDs medication can be used as monotherapy or in combination with MTX for early RA, but requires pregnancy testing and TB testing?
What csDMARDs medication can be used as monotherapy or in combination with MTX for early RA, but requires pregnancy testing and TB testing?
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If a patient is having intolerable GI side effects with PO MTX what options can we offer?
If a patient is having intolerable GI side effects with PO MTX what options can we offer?
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What csDMARDs is recommended for lactating or pregnant patients with RA?
What csDMARDs is recommended for lactating or pregnant patients with RA?
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What medication can be an add-on to MTX to achieve remission, but is not safe for patients with sulfa allergies?
What medication can be an add-on to MTX to achieve remission, but is not safe for patients with sulfa allergies?
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Hydroxychloroquine and Sulfasalazine must be given for at least....
Hydroxychloroquine and Sulfasalazine must be given for at least....
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A patient failed to achieve treatment goals despite receiving an adequate trial of csDMARD monotherapy (ex. MTX), what medication can be used as monotherapy or combined with MTX or other csDMARDs?
A patient failed to achieve treatment goals despite receiving an adequate trial of csDMARD monotherapy (ex. MTX), what medication can be used as monotherapy or combined with MTX or other csDMARDs?
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What is the preferred agent for a patient with RA and Hepatitis B to achieve remission?
What is the preferred agent for a patient with RA and Hepatitis B to achieve remission?
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What is the preferred agent for a patient with RA and NASH to achieve remission?
What is the preferred agent for a patient with RA and NASH to achieve remission?
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What is the preferred agent for a patient with RA and Heart Failure to achieve remission?
What is the preferred agent for a patient with RA and Heart Failure to achieve remission?
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It is important to monitor patients for signs and symptoms of infection when they are on therapies.
It is important to monitor patients for signs and symptoms of infection when they are on therapies.
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What biologic DMARD under the category of TNF inhibitor requires the co-use of MTX due to mouse derived antibodies?
What biologic DMARD under the category of TNF inhibitor requires the co-use of MTX due to mouse derived antibodies?
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What is the classwide toxicities to consider when starting a patient on biologic DMARDs?
What is the classwide toxicities to consider when starting a patient on biologic DMARDs?
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What non-TNF bDMARD can cause activation of latent Hepatitis B, but should be considered for heart failure patients?
What non-TNF bDMARD can cause activation of latent Hepatitis B, but should be considered for heart failure patients?
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What IL-6 receptor agonist from the nonTNF bDMARD group needs TB testing prior to use?
What IL-6 receptor agonist from the nonTNF bDMARD group needs TB testing prior to use?
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What IL-1i can be used at home as a subQ injection, but runs the risk of worsened RA symptoms, GI upset and URI?
What IL-1i can be used at home as a subQ injection, but runs the risk of worsened RA symptoms, GI upset and URI?
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What tsDMARD (JAKi) has a serious risk of DVT, URI and shingles?
What tsDMARD (JAKi) has a serious risk of DVT, URI and shingles?
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Which bDMARD is safe for pregnancy?
Which bDMARD is safe for pregnancy?
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What can be used for immediately symptomatic relief of RA while the DMARD is slowly taking effect?
What can be used for immediately symptomatic relief of RA while the DMARD is slowly taking effect?
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What bridge therapy can reduce inflammation and slow disease progression while DMARDs are being started?
What bridge therapy can reduce inflammation and slow disease progression while DMARDs are being started?
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What is NOT a consideration for the DAS28-CRP Assessment used for symptom and disease monitoring for RA?
What is NOT a consideration for the DAS28-CRP Assessment used for symptom and disease monitoring for RA?
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A patient presents with moderate to high disease activity RA and had symptoms start less than 3 months ago. What is the best first line option?
A patient presents with moderate to high disease activity RA and had symptoms start less than 3 months ago. What is the best first line option?
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A patient presents with moderate to high disease activity RA and had symptoms start less than 3 months ago. What is the best option if they already MAXED MTX at 20mg/wk but are still having symptoms
A patient presents with moderate to high disease activity RA and had symptoms start less than 3 months ago. What is the best option if they already MAXED MTX at 20mg/wk but are still having symptoms
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Study Notes
RA Treatment and Management
- RA treatment should be adjusted frequently until the target is achieved, as early diagnosis and aggressive treatment reduce disease progression and prevent joint damage.
- The preferred initial monotherapy for patients with RA should be started within 3 months, and for those with moderate to high disease activity who cannot take methotrexate, alternative medications like leflunomide or sulfasalazine can be used.
Methotrexate (MTX) and Contraindications
- Methotrexate is a preferred medication for RA, but contraindications include hypersensitivity to methotrexate, severe liver disease, and immunodeficiency.
- Folic acid should be started with methotrexate to reduce side effects, and a chest X-ray is recommended before starting methotrexate.
csDMARDs and Alternative Options
- csDMARDs like leflunomide and sulfasalazine can be used as monotherapy or in combination with MTX for early RA, but require pregnancy testing and TB testing.
- For patients with intolerable GI side effects with PO MTX, alternative options include subcutaneous methotrexate or oral sulfasalazine.
- Hydroxychloroquine and sulfasalazine must be given for at least 6 months to achieve optimal results.
Biologic DMARDs and Combination Therapy
- Biologic DMARDs like TNF inhibitors can be used as monotherapy or combined with MTX or other csDMARDs for patients who failed to achieve treatment goals with csDMARD monotherapy.
- The preferred agent for a patient with RA and Hepatitis B is TNF inhibitor, while for a patient with RA and NASH, the preferred agent is IL-6 receptor agonist.
- For a patient with RA and Heart Failure, the preferred agent is non-TNF biologic DMARD.
Safety and Monitoring
- It is essential to monitor patients for signs and symptoms of infection when on therapies.
- Biologic DMARDs have classwide toxicities, including infection and malignancy.
- The TNF inhibitor, infliximab, requires the co-use of MTX due to mouse-derived antibodies.
- Non-TNF biologic DMARD, tocilizumab, can cause activation of latent Hepatitis B, but should be considered for heart failure patients.
IL-1i and JAKi
- The IL-1i, anakinra, can be used at home as a subQ injection, but runs the risk of worsened RA symptoms, GI upset, and URI.
- The JAKi, tofacitinib, has a serious risk of DVT, URI, and shingles.
Pregnancy and Lactation
- Sulfasalazine is recommended for lactating or pregnant patients with RA.
- The biologic DMARD, certolizumab, is safe for pregnancy.
Symptomatic Relief and Bridge Therapy
- Glucocorticoids can be used for immediately symptomatic relief of RA while the DMARD is slowly taking effect.
- Bridge therapy, such as glucocorticoids or NSAIDs, can reduce inflammation and slow disease progression while DMARDs are being started.
DAS28-CRP Assessment
- The DAS28-CRP Assessment is used for symptom and disease monitoring for RA, but does not consider patient's global assessment of disease activity.
Treatment Approach
- For patients with moderate to high disease activity RA and symptoms starting less than 3 months ago, the best first-line option is methotrexate or alternative csDMARDs.
- For patients who already maxed MTX at 20mg/wk but are still having symptoms, the best option is to add a biologic DMARD or switch to a different csDMARD.
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Test your knowledge on the frequency at which RA treatment should be adjusted until the target is achieved. See if you understand when and how often modifications should be made to the treatment plan.
