Rheumatoid Arthritis Medications Quiz
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Questions and Answers

Which drug is a folic acid antagonist and primarily used for its immunosuppressant properties in rheumatoid arthritis?

  • Hydroxychloroquine sulfate
  • Sulfasalazine
  • Methotrexate (correct)
  • Leflunomide

    • Which DMARD is known for its longer half-life and the risk of hepatic failure?

  • Azathioprine
  • Sulfasalazine
  • Methotrexate
  • Leflunomide (correct)

    • Which of the following is NOT commonly used as a DMARD due to the availability of better alternatives?

  • Hydroxychloroquine sulfate
  • Leflunomide
  • Ciclosporin (correct)
  • Methotrexate

    • What is the primary mechanism of action through which sulfasalazine exerts its anti-inflammatory effects?

    <p>Inhibiting prostaglandins and leukotrienes (C)</p> Signup and view all the answers

    What significant side effect is associated with methotrexate treatment?

    <p>Mucositis and hepatotoxicity (D)</p> Signup and view all the answers

    Which drug's therapeutic effect requires co-administration of folic acid supplements to reduce side effects?

    <p>Methotrexate (A)</p> Signup and view all the answers

    Which DMARD acts by blocking dihydroorotate dehydrogenase?

    <p>Leflunomide (D)</p> Signup and view all the answers

    Which side effect is shared by both methotrexate and sulfasalazine?

    <p>GI disturbances (D)</p> Signup and view all the answers

    Which DMARD is specifically indicated for its anti-inflammatory effects through inhibition of pro-inflammatory cytokines?

    <p>Sulfasalazine (C)</p> Signup and view all the answers

    What is a major concern when using immunosuppressant drugs like methotrexate and leflunomide?

    <p>Increased susceptibility to infections (C)</p> Signup and view all the answers

    What is the primary goal in treating rheumatoid arthritis early in the disease?

    <p>To control the disease early on (A)</p> Signup and view all the answers

    Which drug class is classified as having little effect on disease progression in RA?

    <p>NSAIDs (D)</p> Signup and view all the answers

    What is a known side effect of glucocorticoids such as prednisolone?

    <p>Cushing Syndrome (A)</p> Signup and view all the answers

    What type of DMARDs may limit the progression of rheumatoid arthritis?

    <p>Conventional DMARDs (cDMARDs) (D)</p> Signup and view all the answers

    Which glucocorticoid formulation is designed to release medication in accordance with circadian rhythms?

    <p>Lodotra (prednisone) (D)</p> Signup and view all the answers

    What mechanism do glucocorticoids primarily use to exert their anti-inflammatory action?

    <p>Inhibit inflammatory cell action (A)</p> Signup and view all the answers

    What is the method of administration for glucocorticoids mentioned in the content?

    <p>Oral, intramuscular or intraarticular (C)</p> Signup and view all the answers

    Which of the following cytokines is NOT mentioned as being inhibited by glucocorticoids?

    <p>IL-4 (D)</p> Signup and view all the answers

    What is the potential benefit of using Lodotra over standard prednisone?

    <p>Improved early-morning joint stiffness (B)</p> Signup and view all the answers

    In the context of rheumatoid arthritis, which of the following is NOT a part of the overall treatment approach?

    <p>Exclusive surgical intervention (D)</p> Signup and view all the answers

    What is the primary mechanism of action for drugs that aim to prevent autoimmune responses in rheumatoid arthritis?

    <p>Prevent antigen processing by immune cells (C)</p> Signup and view all the answers

    Which of the following biological DMARDs is NOT indicated for moderate to severe rheumatoid arthritis?

    <p>Rituximab (C)</p> Signup and view all the answers

    Which of the following targets IL-6 in its mechanism of action?

    <p>Sarilumab (B)</p> Signup and view all the answers

    In the treatment of rheumatoid arthritis, when is the use of biological DMARDs generally recommended?

    <p>After failure of one conventional DMARD (D)</p> Signup and view all the answers

    What concern is associated with overdosing on certain RA treatments?

    <p>Cardiovascular and psychiatric effects (C)</p> Signup and view all the answers

    Which class of biological DMARDs would likely be prescribed alongside methotrexate in a triplet therapy for rheumatoid arthritis?

    <p>Cytokine inhibitors (A)</p> Signup and view all the answers

    Which of the following biological DMARDs is a fusion protein designed to act as a decoy receptor for TNF?

    <p>Etanercept (B)</p> Signup and view all the answers

    What is the classification of Sarilumab in the context of RA treatment?

    <p>Human monoclonal antibody (C)</p> Signup and view all the answers

    Which of the following factors is a critical consideration when using biological DMARDs?

    <p>Potential for immunogenicity (D)</p> Signup and view all the answers

    What is the role of Rituximab in rheumatoid arthritis treatment?

    <p>Treatment for patients unresponsive to anti-TNF therapy (A)</p> Signup and view all the answers

    Which class of drugs is primarily used in the treatment of rheumatoid arthritis to reduce inflammation and prevent joint damage?

    <p>DMARDs (A)</p> Signup and view all the answers

    What is the primary immune response type involved in rheumatoid arthritis?

    <p>Th1 immune response (C)</p> Signup and view all the answers

    Which of the following cytokines is NOT typically associated with rheumatoid arthritis?

    <p>IL-10 (C)</p> Signup and view all the answers

    Which biological drug is specifically classified as a TNF-alpha inhibitor?

    <p>Infliximab (B)</p> Signup and view all the answers

    Janus kinase (JAK) inhibitors are primarily used to treat which type of conditions?

    <p>Autoimmune diseases (D)</p> Signup and view all the answers

    What complication is most associated with the use of JAK inhibitors in treatment?

    <p>Serious infections (D)</p> Signup and view all the answers

    At what point in the disease course of rheumatoid arthritis might a patient experience significant stiffness in the mornings that improves throughout the day?

    <p>In the early stages of the disease (D)</p> Signup and view all the answers

    Which serological test is considered most specific for diagnosing rheumatoid arthritis?

    <p>Anti-CCP antibodies (B)</p> Signup and view all the answers

    What is the typical treatment approach for rheumatoid arthritis?

    <p>Long-term use of DMARDs and biologics (D)</p> Signup and view all the answers

    Which of the following drugs is a synthetic DMARD used in rheumatoid arthritis treatment?

    <p>Tofacitinib (D)</p> Signup and view all the answers

    Flashcards

    Anti-inflammatory drugs for RA

    Medications that work by reducing inflammation but have little effect on the progression of rheumatoid arthritis (RA).

    Disease Modifying Anti-Rheumatic Drugs (DMARDs)

    A group of medications that can potentially slow down the progression of rheumatoid arthritis (RA).

    Conventional DMARDs (cDMARDs)

    A type of DMARDs that are commonly used to treat rheumatoid arthritis (RA).

    Biologics

    A type of DMARDs that are newer and more targeted in their action compared to cDMARDs.

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    Glucocorticoids

    A class of medications that are often used as a 'bridging' treatment for rheumatoid arthritis (RA), providing rapid relief from inflammation and symptoms.

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    Prednisolone

    A well-known glucocorticoid medication used to treat rheumatoid arthritis (RA) and other inflammatory conditions.

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    Cushing Syndrome

    The condition that can occur as a side effect of long-term glucocorticoid use.

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    Lodotra (Prednisolone)

    A type of prednisolone tablet designed to release the medication over a longer period, mimicking the natural cortisol rhythm of the body.

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    Cortisol

    The natural hormone produced by the body that plays a role in regulating inflammation and stress response.

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    Modified release formulation

    The release of medication from a tablet or capsule over time, allowing for a more consistent level of medication in the body.

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    Early-morning stiffness in RA

    The tendency for symptoms of rheumatoid arthritis (RA) to be worse in the early morning hours.

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    What are DMARDS?

    Drugs that modify the progression of Rheumatoid Arthritis (RA). Includes conventional (cDMARDS) and biologic (bDMARDS) types.

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    What are cDMARDS?

    Conventional DMARDs are traditional medications used to treat Rheumatoid Arthritis (RA) by affecting the immune system. They are typically taken orally.

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    How does Methotrexate work?

    Methotrexate is a cDMARD that works by inhibiting the enzyme dihydrofolate reductase, which is critical for DNA synthesis. This slows down the growth of cells, including those involved in inflammation.

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    How does Leflunomide work?

    Leflunomide is a cDMARD that inhibits the enzyme dihydroorotate dehydrogenase, which is essential for pyrimidine synthesis, which is involved in cell growth and division. This effect targets rapidly dividing immune cells.

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    How does Sulfasalazine work?

    Sulfasalazine is a cDMARD that acts as a pro-drug. It is broken down in the gut into 5-aminosalicylate (5-ASA) and Sulfapyridine. 5-ASA has anti-inflammatory effects in the gut, while Sulfapyridine is absorbed into the bloodstream and has wider anti-inflammatory effects.

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    What are Biologic DMARDs?

    Biologic DMARDs (bDMARDS) are a newer class of drugs used to treat Rheumatoid Arthritis (RA). They target specific proteins involved in inflammation, which are often overproduced in RA.

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    How are bDMARDS used?

    bDMARDS are typically administered via injection or infusion and are used in more severe cases of RA, often when cDMARDS have not been effective.

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    What are some examples of bDMARDS?

    Examples of bDMARDS include TNF inhibitors, IL-1 inhibitors, and JAK inhibitors. Each type targets a different protein involved in inflammation.

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    What are some common side effects of DMARDS?

    Side effects of DMARDS can vary depending on the drug, but some common ones include: nausea, vomiting, diarrhea, liver problems, and a weakened immune system.

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    Why is early and aggressive RA treatment important?

    Treating RA aggressively and early is crucial to prevent permanent joint damage and improve long-term outcomes. DMARDS play a key role in this proactive approach.

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    Biological DMARDs

    A type of DMARD that targets specific proteins involved in the immune system's attack on the joints.

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    Anti-TNF-alpha therapy

    A biological DMARD that blocks the activity of TNF-alpha, a protein involved in inflammation.

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    Anti-IL-6 therapy

    A biological DMARD that blocks the activity of IL-6, another key player in inflammation.

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    Methotrexate

    A cDMARD used in triple therapy for moderate to severe RA.

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    Sulfasalazine

    A cDMARD used in triple therapy for moderate to severe RA.

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    Leflunomide

    A small molecule cDMARD that is often used as the first-line treatment for RA.

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    Triple therapy

    A combination of cDMARDs used to treat more severe RA, often including methotrexate and sulfasalazine.

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    Treatment flowchart: NICE

    A treatment flowchart for RA developed by the National Institute for Health and Care Excellence, a UK organization.

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    Janus Kinase (JAK) Inhibitors

    A category of drugs that block the signaling of Janus kinases, key enzymes involved in inflammation. Examples include tofacitinib, baricitinib, and upadacitinib.

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    Tumor Necrosis Factor-alpha (TNF-alpha)

    A prominent cytokine involved in rheumatoid arthritis, often targeted by biologic DMARDs.

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    Interleukin-1 (IL-1)

    A cytokine involved in rheumatoid arthritis, particularly important in the early stages of the disease.

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    Interleukin-6 (IL-6)

    A cytokine involved in rheumatoid arthritis, associated with joint inflammation and pain.

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    Rheumatoid Arthritis (RA)

    A chronic autoimmune disease characterized by inflammation of the synovial joints, leading to joint pain, stiffness, and eventual destruction.

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    Th1 Immune Response

    A type of immune response involving T cells and macrophages, which is dominant in rheumatoid arthritis.

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    Early Morning Stiffness

    A common symptom of rheumatoid arthritis, often worse in the morning.

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    Anti-CCP Antibodies

    A blood test used to detect antibodies against citrullinated proteins, indicating a higher risk for rheumatoid arthritis.

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    Study Notes

    Rheumatoid Arthritis Treatment

    • Rheumatoid arthritis (RA) is a debilitating autoimmune disease
    • The initial impact of RA causes significant disability
    • The goal is to control RA early to minimize long-term effects
    • Treatment involves: patient education, healthcare professional management, medication, and surgery

    Drugs for RA

    • Anti-inflammatory drugs: These have little effect on disease progression
      • Nonsteroidal anti-inflammatory drugs (NSAIDs)
      • COX-2 inhibitors
      • Glucocorticoids (e.g., prednisolone)
    • Disease-Modifying Anti-Rheumatic Drugs (DMARDs): Compounds that may limit disease progression
      • Conventional DMARDs (cDMARDs)
      • Biologics

    Glucocorticoids (e.g., Prednisolone)

    • Useful "bridging" drug
    • Administered orally, intramuscularly, or intra-articularly
    • Actions: anti-inflammatory and immune suppression
      • Inhibit cytokine gene expression (IL-1, IL-2, IL-6, TNFα)
      • Inhibit inflammatory cell action (decreasing T cell activity and proliferation)

    Side Effects of Glucocorticoids (Cushing Syndrome)

    • Euphoria (though sometimes depression or psychosis)
    • Emotional lability
    • Buffalo hump
    • Hypertension
    • Moon face (plethoric cheeks)
    • Increased abdominal fat
    • Avascular necrosis of femoral head
    • Easy bruising
    • Thinning skin
    • Thin arms and legs, muscle wasting
    • Poor wound healing
    • Osteoporosis
    • Tendency to hyperglycemia
    • Negative nitrogen balance
    • Increased appetite
    • Increased susceptibility to infection
    • Obesity

    Steroid Formulations (e.g., Lodotra)

    • Prednisone modified-release formulation
    • Activated approximately 6 hours post-ingestion
    • Taken with water, after food; do not chew
    • Released to coincide with circadian rhythms of cortisol & disease symptoms (peak early morning)
    • Studies show improvement in early morning joint stiffness symptoms

    DMARDs (Disease-Modifying Anti-Rheumatic Drugs)

    • Conventional DMARDs (e.g., methotrexate, azathioprine, cyclosporin, leflunomide, sulfasalazine, sodium aurothiomalate, penicillamine, hydroxychloroquine sulfate)
    • Biologic DMARDs
    • Effective in limiting disease progression
    • 90% of RA joint involvement occurs within the first year; early aggressive treatment is crucial.

    DMARDS Effects

    • Shown to reduce swelling, pain, and improve joint function

    cDMARDs (Conventional DMARDs)

    • Methotrexate
    • Azathioprine
    • Cyclosporin
    • Leflunomide
    • Sulfasalazine
    • Sodium aurothiomalate
    • Penicillamine
    • Hydroxychloroquine sulfate

    Immunosuppressants

    • Induce and maintain remission, but impair immune response (i.e., increasing susceptibility to infection)
    • Methotrexate and leflunomide are commonly used .
    • Azathioprine and ciclosporin are less frequently used due to better alternatives

    Methotrexate

    • Folic acid antagonist and inhibitor of dihydrofolate reductase. Inhibits DNA synthesis
    • Also interferes with IL-1 proinflammatory actions
    • Also promotes adenosine release (anti-inflammatory)
    • Side effects: myelosuppression, mucositis, GI disorders, hepatotoxicity, pneumonitis, teratogenic
    • Co-administration of folic acid supplements reduces myelosuppression and mucositis

    Leflunomide

    • Prodrug converted to teriflunomide in the body
    • Inhibits pyrimidine synthesis (blocking dihydroorotate dehydrogenase)
    • Targets rapidly dividing cells (T-cells)
    • Used for moderate to severe rheumatoid arthritis
    • Side effects: GI disturbances, peripheral neuropathy, risk of hepatic failure
    • Long half-life

    Sulfasalazine

    • Broken down by gut bacteria (azoreductase) to 5-aminosalicylate (5-ASA) and sulfapyridine
    • Absorbed into systemic circulation
    • Acts in the lumen to have anti-inflammatory effects
    • Therapeutic use through inhibition of PGs and LTs, and pro-inflammatory cytokines (IL-1, TNFα)
    • Side effects: GI disturbances, malaise, headache, severe adverse reactions (including reduced WBC counts, caused by sulfapyridine)

    Hydroxychloroquine sulfate

    • Weak DMARD with a slow onset of action
    • Prevents antigen processing by immune cells, preventing immune response
    • Effective against autoimmune responses
    • Use in mild RA, with methotrexate and sulfasalazine (triple therapy)
    • Potential serious side effects (especially with overdose), including cardiovascular and psychiatric effects

    Biological DMARDs

    • Many treatment options (see Canvas)
    • Recommended when conventional therapies are ineffective
    • Target numerous pathways in RA, specifically TNF alpha, other cytokines (e.g., IL-6), and other targets
    • Examples include: Etanercept, Infliximab, Anakinra, Abatacept, Tocilizumab, Sarilumab, Rituximab

    International Non-Proprietary Names (INNs) for Antibodies

    • Provides common names for antibodies used in RA treatment across different origins (Chimeric, Humanised, Human) e.g., Infliximab, Tocilizumab, Sarilumab

    Immunogenicity

    • Different antibody origins (murine, chimeric, humanized, human) exhibit varying levels of immunogenicity (i.e., a reduced reaction from the body)

    Biological Therapy for RA

    • Includes drugs such as Etanercept, Infliximab, Anakinra, Abatacept, Tocilizumab, Sarilumab, Rituximab
    • Used in conjunction with methotrexate (MTX)
    • Targeting TNF, IL-1, IL-6 receptor, and other targets

    Treatment Flowchart NICE

    • Mono-therapy with cDMARDs (MTX, Leflu, Sulfasalazine, Hydroxychloroquine) for mild cases
    • MTX with Biological therapies (TNFalpha inhibitors)
    • Other biological drugs (e.g., Rituximab) with or without MTX
    • Other biological drugs (e.g., Sarilumab, tocilizumab) with or without MTX

    Other Compounds

    • Synthetic DMARDs (e.g., tofacitinib, baricitinib, upadacitinib)
    • Janus kinase (JAK) inhibitors
    • Used under expert supervision
    • Risks include: cardiovascular events, venous thromboembolism, malignancies, serious infections, and increased mortality

    Rheumatoid Arthritis vs. Osteoarthritis

    • Differentiated based on features like joint involvement patterns (symmetrical/asymmetrical), presence of nodules, and morning stiffness duration, cartilage loss, inflamed synovium
    • RA is autoimmune, while osteoarthritis is degenerative

    Key Differences between RA and OA

    These are summarized in a table

    Self-Assessment Questions

    • Questions about RA diagnosis, pathogenesis-implicated cytokines, differences between anti-inflammatory and immunosuppressant drugs, and biological drugs used for treatment.

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