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MakeWayforRA:AnOverviewofRheumatoidArthritis

MikeCrowe,PharmD

ClinicalPharmacist

May15,2012

Objectives

1. Recognizethepathophysiology, clinicalpresentation,and

complicationsofrheumatoidarthritis.

2. Explaintheavailabletreatmentsoptionsforpatients

presentingwithRA,including: Preferredtreatments,givenspecificpatientcharacteristicsand

treatmenthistory.

Differencesinmechanismofactionamongstallavailabletreatments. Sideeffectsandcontraindicationsofeachavailabletreatment.

3. CounselpatientsregardingthepossiblesideeffectsofRA

agentsandtheirpropermanagement.

Introduction14

Chronic,autoimmunediseaseUnknowncause

Complicationsnotlimitedtojoints TreataggressivelyTargetclinicalremission

Epidemiology3,4

Prevalenceo 1%onaverage

o 0.1%inruralAfricans

, ,

RacedoesnotappeartoimpactPeakonsetbetween50and75

RUAwakeforRA?

Whatistherelationshipbetweengenderand

rheumatoidarthritis?

. b. Womenaremorelikelytodevelop

Epidemiology3,4

Womenhave23timesgreaterriskAges1545,6timesgreaterEstrogenthoughttoplayarole

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Epidemiology3,4

Identicaltwinhas30timeshigherrisk

Childrenhave6timeshigherriskSharedEpitope

o HLADR1,HLADR4,HLADR14

o FoundinmajorityofRApatients

o DR4confers3.5xgreaterrisk

o NotrequiredforRA

EnvironmentalRiskFactors1,4

Negative

o Cigarettesmokingo Infection

Protectiveo Alcohol

o Breastfeeding

o Highersocioeconomicstatus

Pathophysiology1,3

Autoimmunedisease

Nolongerdifferentiatebetweenselfandnonself

Synovialandotherconnectivetissuesareattacked

Leadstochronicinflammation ofsynovialtissue

Proliferationleadstodestructionofboneandcartilage

Pathophysiology1,3,5

CitrullinationduetoerrorsinDNAtranscription

o Fibrinogen

o Collagen

o Others

AntigenpresentingcellspresenttoTcell

o Dendriticcells

o Macrophages

o Bcells

StimulatesTcellsandBcells

Pathophysiology1,3,5

Bcells

Plasmacells autoantibodies (RF,antiCCP)

PossessCD20cellsurfaceprotein

T cells CD4+proinflammatory(TNF,IL1,IL6)

Activationrequirescostimulation(CD80/CD86)

Proinflammatorycytokinesproducedbyother

immunecellsandarenotlimitedtoTNF,IL1,IL6

ClinicalPresentation3,6

Insidious onset

MostcommonpresentationtypeClassic

Occursinuptoonethird

Associatedwithmusclepain,fatigue,fever,weightloss,depressionAcuteEpisodic jointinvolvementforhourstodays

Absenceofsymptomsfordaystomonths

40%developRAPalindromic

Typicallyinvolvesalargejoint(e.g.,knee,shoulder)

MaybedaysorweeksbeforemultiplejointsaffectedMonoarthritis

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SignsandSymptoms3,6

Typically>6wksofjointpain/stiffness

o Mostoftensymmetricalo Maybeginunsymmetrical

Generalfatigueandweakness

Lowgradefever

Lossofappetite

LaboratoryMarkers3,6

RFin6070%ofpatients

AntiCCPantibodiescommon Elevatederythrocytesedimentationrate(ESR)

IncreasedWBCcountsinjointfluid

Radiographicfindings

o Jointnarrowing

o Erosions

RUAwakeforRA?

Comparedtoosteoarthritis,thejointsofthehips,

knees,andspineare:

.

b. LesslikelytobeinvolvedinRA

ArticularManifestations3,6

Jointsaffecteddifferfromosteoarthritis(OA)

Morningstiffness>30mins

Adequateexerciserequired

Deformationinlaterstages

ArticularManifestations3,6

AllJoints

Pain

Hands/Wrists

Lossofgrip

Knees/Feet

Popliteal/Baker Swelling

Tender

strength

Inabilityto

performactivitiesofdailylivingorwork

activities

cystsinknees

Hammertoe,

bunions,callusesinfeet

Instabilityorabnormalgait

ExtraarticularManifestations3,6

Cardiacinvolvement

Rheumatoidnodules

Vasculitis

Ocularmanifestations

FeltysSyndrome

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CardiacImpact3,7,8

IncreasedcardiovascularriskinRApatients

o Heartfailureriskdoubledo Riskofcardiovasculardeathincreased50%

RarecomplicationsofRA:o Pericarditis

o Myocarditis

o Conductionabnormalities

RheumatoidNodules3,7,8

Palpablenodulesin2035%ofpatients

o RheumatoidFactoro Erosivedisease

Usuallyasymptomatic;rarelytreated

Localsteroidinjectionmaycauseregression

Vasculitis3,7,8

Inflammatorydestructionofbloodvessels

Occursin

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> 4CriterionIndicatesRA

1987ACRDiagnosis9

MorningArthritisof3

or More JointArthritis of Symmetric

NodulesSerum Radiographic

> 6weeks

Stiffness

AreasHandJoints Arthritis RF Changes

2010ACR/EULARDiagnosis9,10

A . J oi ntInvolvement 1largejoint 0

210largejoints 1

13smalljoints 2

410smalljoints 3

>10joints(> 1small) 5

B. Serology

Tota

lScore

NegativeRFandnegativeACPA 0

LowpositiveRForlowpositiveACPA 2

HighpositiveRForhighpositiveACPA 3

C . A cu tePhaseReactants NormalCRPandnormalESR 0

AbnormalCRPorabnormalESR 1

D. DurationofSymptoms 6weeks 1

6IndicatesRA

RUAwakeforRA?

PatientLMpresentswiththefollowing

characteristics. Whatisyourdiagnosis?

5jointsineachhandareswollen/tender

Hi h ositive RF or hi h ositive ACPA

AbnormallyhighESR

Symptomspersistingfortwomonths

a. LMhasRA

b. LMdoesnothaveRA

GoalsofTherapy3,11

MaintainorImproveQOL

DiseaseActivityorRemission

PreventingJointDestruction

MaintainAbilitytoPerformDailyActivities

ReducePainandInflammation

DiseaseActivityInstruments11

Instrument ThresholdsofDiseaseActivity Levels

Patient ActivityScale(PAS)orPASII

(range010)

Remission:0 to0.25

Low:0.26 to3.7

Moderate:3.71to 8.0

RoutineAssessmentofPatientIndexData3

(range010)

Remission:0 to1.0

Low:>1.0to2.0

Moderate: > 2.0 to 4.0: . .

High:>4.0 to10

ClinicalDisease ActivityIndex

(range076.0)

Remission:< 2.8

Low:>2.8to10.0

Moderate:>10.0to22.0

High:>22

DiseaseActivityScorein28Joints

(range09.4)

Remission: 2.6to 3.2to< 5.1

High:>5.1

SimplifiedDiseaseActivity Index

(range086.0)

Remission:< 3.3

Low:>3.3to< 11.0

Moderate:>11.0to< 26

High:>26

TreatmentOptions3

NonPharmacological

ImproveFunction ReduceRisk

SymptomaticTherapies

NonSteroidal

AntiInflammatory Drugs(NSAIDs)Corticosteroids

DiseaseModifyingAntirheumatic Drugs(DMARDs)

Traditional DMARDs BiologicDMARDs

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RUAwakeforRA?

Whichofthefollowingareappropriate

nonpharmacologicalrecommendationsforapatientdiagnosedwithRA?

a. Losewe g t,e m nate o ntmovement,an

stopsmoking

b. Useassistivedevices,begin/maintainan

exerciseregimen,andobtainimmunizations

ImproveFunction3,30

Rest

Exercise Occupationalandphysicaltherapy

Weightloss

Surgery

ReducingRisk3,30

Cardiovascularriskreduction

o Smoking

o Hypertension

o Hyperlipidemia

o Sedentarylifestyle

Boneprotection

Vaccines

RUAwakeforRA?

TrueorFalse:apatientdiagnosedwithRAmay

useanNSAIDaloneoradiseasemodifyingagent

(DMARD)aloneforlongtermcontroloftheir

.

a. True

b. False

NSAIDs3

Placeintherapy

o Symptomaticrelief

o AdjuncttoDMARD

Maybeusedforsteroidsparingeffect

NSAIDCounseling3

Takewithfood

Donotuseinlatepregnancy

Monitorforandreport

o Signsofimpairedkidneyfunction

o SignsofMIorstroke

Reportothermedications

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Corticosteroids3,13

Placeintherapy

o Bridgetherapy

o Treatmentofacutesynovitis(flares)

o TypicallynotusedinabsenceofDMARD

Adverseeventsassociatedwithlongtermuse

Routes

o Oral(taperasquicklyaspossibletolowesteffectivedose)

o IMdepots(longerlasting)

o Intraarticular(lesssystemiceffectsbutalsolocalrisks)

CorticosteroidCounseling3,13

Monitorforandreport:

o Hypertension

o Bloodglucose

o Signsofinfection

o Adrenocorticalinsufficiency(fatigue,weightloss,etc.)

Takeoralproductwithfood

EnsureadequateintakeofcalciumandvitaminD

Informphysicianandpharmacistofothermedications

DecidingWhatDMARDtoStart11,12

1. DiseaseActivity(covered)

2. DiseaseDuration

EarlyRA( 6monthsormeeting1987ACRCriteria)

3. FeaturesofPoorPrognosis(> 1ofthefollowing)

Functionallimitation(e.g.,HAQorsimilar) Extraarticulardisease(e.g.,nodules,vasculitis,etc.)

Positiverheumatoidfactor Positiveanticycliccitrullinatedpeptideantibodies Bonyerosionsbyradiograph

WhattoStartinEarlyRA12

RUAwakeforRA?

PatientEHhasbeendiagnosedwithRAoneweek

ago. Diseaseactivityislow,andthereareno

markersofpoorprognosis. Whattypeoftherapy

a. TraditionalDMARDmonotherapy

b. TraditionalDMARDcombotherapy

c. AntiTNFtherapywithmethotrexate

TraditionalDMARDs3,12

Methotrexate (MTX)Methotrexate (MTX)

Leflunomide

(LEF)

Leflunomide

(LEF)

CommonAzathioprineAzathioprine

MinocyclineMinocycline

Rare

Sulfasalazine(SSZ)Sulfasalazine(SSZ)

Hydroxychloroquine(HCQ)Hydroxychloroquine(HCQ)

CyclosporineCyclosporine

Gold(IMorPO)Gold(IMorPO)

CyclophosphamideCyclophosphamide

PenicillaminePenicillamine

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TraditionalDMARDOverview1417

FirstusedforRAin1951,goldstandardoftraditionalDMARDs

Lowcost,favorableefficacy,moststudiedDMARDMTX

AlternativetoMTXwhenMTXfailsorisintolerable

esspo en a or ver ox c ycompare o , u morecos y

Anoptioninpatients withalldiseasedurationsandactivitylevels

Moreeffective andtolerablethanHCQ,similarefficacytoLEFSSZ

Relativelysafe,acceptableforpatients withlowdiseaseactivity

Lacksmyelosuppressive,hepatic,andrenaltoxicitiesHCQ

TraditionalDMARDMOA/Kinetics1417

Inhibitspurinesynthesisandinflammatorycytokineproduction

Onset:23weeks MTX

Antiinflammatoryandantiproliferativeactivity

n se : wee s

MOAunknown

Onset:412weeks SSZ

MOAunknown

Onset:atleast4weeks,failurenotconsideredfor6months HCQ

TraditionalDMARDDosing1417

Oral,IMorSubQ:7.515mgweekly,nottoexceed2025mg/week

Doses>1517.5mgshouldbegivenIMorSubQMTX

Oral:100mgdailyfor3daysthen1020mgdaily

o a n g oseno recommen e ya prac oners

Oral:5001,000mgdailyaftermealordividedBID

Mayincreaseto1gBID,maxdose3g/daySSZ

Oral:400600mgdailytakenwithfood

After13months maydecreaseto200400mgdaily

HCQ

TraditionalDMARDCI/Precautions1417

CI:pregnancyorpotentialpregnancy(orpartnerof),breastfeeding

Precaution:renal,hepatic,orimmunedeficiency

Precaution:manydrugdruginteractionsMTX

CI:pregnancyorpotentialpregnancy(orpartnerof)

Precaution:renal,hepatic,orimmunedeficiency

Precaution:usewithwarfarin

CI:urinaryobstruction

Precaution:pregnancy, breastfeeding

Precaution:usewithwarfarinandantibioticsSSZ

CI:retinalorvisualchangesfromprior4aminoquinolonecompound

CI:breastfeeding

Precaution:psoriasispatients

HCQ

TraditionalDMARDSideEffects1417

NVD;1mgfolicaciddailytoreducestomatitis

Myelosuppression,thrombocytopenia,leukopenia,hepatotoxicityMTX

Elevatedliverenzymes(lesshepatotoxicthanMTX)l l l yelosuppress on,gastro ntest nals dee ects,alopec a

NVD;minimizedthroughdosetitrationanddosingwithfood

Rash;minimizedthroughuseofcorticosteroids/antihistamines

Colorchangesinurineand/orskin(yellow/orange)SSZ

Rash,diarrhea,photosensitivity

Maculardamage,cornealtoxicity, retinopathy(eyeexamq912months)HCQ

NamethatTraditionalDMARD

IampregnancycategoryX. Icanbedosedeither

orallyorsubcutaneously. Whattraditional

DMARDamI?

a. Methotrexate

b. Leflunomide

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NamethatTraditionalDMARD

Igonicelywithameal,butbecarefulifyoure

eatingthatmealoutsideinthesun. Youmightgetalittleredwithoutsunblock. What

a. Sulfasalazine

b. Hydroxychloroquine

NamethatTraditionalDMARD

UnlikemyfellowtraditionalDMARDs,Ihavenot

beenknowntocausevisionchangesorurineorskincolorchanges. Myclosecousincanbedosed

,

hepatotoxicity. Whattraditional

DMARDamI?

a. Leflunomide

b. Hydroxychloroquine

TraditionalDMARDCounseling1417

Counseling

Avoidpregnancy (women/partners ) X X

Takewithfood X X

Hydrate andreport renaltoxicity X X

MTX LEF SSZ HCQ

Reportvisionchanges X

Maycausephotosensitivity X X

Reportrashesimmediately X X

Hepatictoxicity X X X

GItoxicity X X

Hematologictoxicity X X X*

BiologicDMARDs3,14,18

Effectiveinpatientsthatfailtraditionalagents

OftencombinedwithMTX

Greaterriskofbacterialinfectionso Tighterrestrictionsforcontraindicationstotherapy

o Dosesmaybeheldifsignificantinfectionsdevelop

o BaselineTBscreeningtoidentifylatentinfection

BiologicDMARDsTimeline3,14,18

Year Medication Brand BiologicalTarget

1998 Etanercept Enbrel TNF

1999 Infliximab Remicade TNF

2001 Anakinra Kineret IL1

2002 Adalimumab Humira TNF

2005 Abatacept Orencia CD80/CD86ofT cell

2006 Rituximab Rituxan CD20ofBcell

2009 Golimumab Simponi TNF

2009 Certolizumab Cimzia TNF

2010 Tocilizumab Actemra IL6

TNF InhibitorsUseinRA3,14,18

TypicallyfirstbiologicDMARDused

Historicallysimilarefficacies

ACRrecommendationsdonotdifferentiate

lossofefficacyisafeasibleoption

Improvementscanoccurwithinweeks,but

maytakeuptothreemonths

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TNF InhibitorsStructure&Dosing3,14,18

Medi cation ChemicalConstruct Dosing

Etanercept

(Enbrel)

Fusionprotein(2TNFreceptors

linkedtohumanFcfragment)

50mgSubQonceweeklyor

25mgtwiceweekly

Infliximab

(Remicade)

Murine/humanchimeric

monoclonalantibody(MAb)

3mg/kgIVonweeks0,2,6

andevery8weeks

thereafter(withMTX)

Adalimumab

(Humira)FullyhumanMAb

40mgSubQ

everyotherweek

Golimumab

(Simponi)FullyhumanMAb

50mgSubQoncemonthly

(withMTX)

Certolizumab

(Cimzia)

PegylatedhumanizedFab

fragment(noFcregion)

400mgsubQweeks0,2,4,

then200mgevery2weeks

or400mgevery4weeks

RUAwakeforRA?

Whatcounselingpointsshouldthepharmacist

providetoapatientreceivingaTNFblocker?

.

immediatelyafterremovingfrom

thefridge

b. Usegoodhygiene,washingyourhands

regularlyandreportingsignsofinfectionas

soonastheyoccur

TNFAdverseEvents3,14,18,19

Headache

Injectionsitereactionso Erythema,edema,pruritis,pain

o Lastafewdays,butfrequencydecreaseswithtime

o Rotateinjectionsitesandallowtoreachroomtemperature

Infusionreactionso Fever,chills,pruritis,rash,nausea

o Slowinfusionrate

o PremedicatewithAPAP,NSAIDs,orcorticosteroids

Antiinfliximabantibodiesin721%ofpatients

TNFAdverseEvents3,14,18,19

Myelosuppression(rare)

Increasedriskofinfectionorreactivationo URTIs,UTIs

o Invasivefungalandotheropportunisticinfections

o LatentTBandlatent/unrecognizedHBV

Casereportsofdemyelinatingsyndromes

Heartfailureexacerbation

Malignancyriskcontroversial

Anakinra(Kineret)3,14,18

Interleukin1(IL1)receptorantagonistMOA

100mgsubcutaneouslydaily(PFS)

Dose LessefficaciousthanantiTNFs

UsuallyineffectiveinTNFnonrespondersPIT

OnetothreemonthsOnset

Injectionsitereactionsinupto80%

Maylast24weeks,decreasingovertimeADEs

Abatacept(Orencia)3,14,18

TcellcostimulationblockerviaCD80andCD86MOA

IV:5001000mgatweeks0,2,4,andevery4weeksafter SubQ:125mgonceweekly

TypicallyreservedforTNFnonresponders

Approximately50%ofTNFnonresponderswillrespondPIT

OnetothreemonthsOnset

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AbataceptAdverseEvents3,14,18

Nausea(10%orgreater)

Infection(URTI,nasopharyngitis) Infusionreactions(dizziness,HTN,headache)

ExacerbationofCOPD

Rituximab(Rituxan)3,14,18

DepletesBcellsbybindingtosurfaceCD20

Durationofeffectvaries,butcanlastseveralmonths

Chimericmonoclonal antibody

MOA

Two1,000mgIVinfusionsseparatedbytwoweeks+MTX

Retreatmentinresponders maybeconsidered after> 4months

IndicatedforpatientsthatfailedoneormoreantiTNFtherapiesPIT

TypicallytwomonthsOnset

RituximabAdverseEvents3,14,18

Infusionreactions(upto35%ofpatients)o Fever,chills,headache,nausea,cough,rash

o IVmethylprednisolone 30minutesprior

o APAPorantihistaminesifneeded

Increasedriskofinfectionsorreactivationof

infection,includingPML

Antibodiesinupto6%aftersecondinfusion

Tocilizumab(Actemra)3,14,18

InhibitsbindingofIL6toitsreceptors

HumanizedMAbMOA

4 mg/kgIVinfusioneveryfourweeks

Phase3Trial:162mgSubQonceweeklymetprimaryendpoint

IndicatedforpatientsthatfailedoneormoreantiTNFtherapiesPIT

Improvementmaybeseenwithinweeks

Up tothreemonthsforfulleffectOnset

TocilizumabAdverseEvents3,14,18

Infusionreactions

Hyperlipidemia(increasedTC,HDL,LDL,TGL)

Increasedliverenzymes

, Increasedinfectionrisk

Gastrointestinalperforation

NamethatBiologicDMARD

IamadministeredIV. Becauseyourbodymight

developantibodiesagainstme,mydoseor

frequencyofadministrationmayhaveto

.

a. Infliximab(Remicade)

b. Abatacept(Orencia)

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NamethatBiologicDMARD

IwasthefirstinmyclassandImstillvery

populartoday. Iamusuallygivenonceweekly,buttheFDAapprovedmetobesplitupinto

.

DMARDamI?

a. Abatacept(Orencia)

b. Etanercept(Enbrel)

NamethatBiologicDMARD

IprettydarngoodatwhatIdo;Iminaclassall

alone. Ionlyhavetobegivenoncemonthly,butunfortunatelyIcanelevatecholesterollevels. If

,

onceweeklysubcutaneousinjection.

WhatbiologicDMARDamI?

a. Tocilizumab(Actemra)

b. Adalimumab(Humira)

NamethatBiologicDMARD

Imstartedwithaloadingdoseof400mgat

weeks0,2,and4soIcangettoworksooner.

AfterthatIcanbegivenjustoncemonthly. Let

,

Imaytakeupto3monthstoreachfull

effectiveness. WhatbiologicDMARDamI?

a. Certolizumabpegol(Cimzia)

b. Golimumab(Simponi)

NamethatBiologicDMARD

YoullseemehelpingRApatientsquiteoften. Im

a40mgsubcutaneousinjection,givenevery

otherweek. Toavoidinjectionsitereactions,

temperatureandtorotateinjectionsites.

WhatbiologicDMARDamI?

a. Etanercept(Enbrel)

b. Adalimumab(Humira)

AssessingTherapyEfficacy20

ACRResponseRateso ACR20(20%improvedtender/swollen jointcount)

o ACR50(50%improvedtender/swollen jointcount)

o ACR70(70%improvedtender/swollen jointcount) PlusXpercentimprovementin> 3:

o Patientsglobalassessment

o Physiciansglobalassessment

o Patientsassessmentofpain

o Degreeofdisability

o Levelofacutephasereactant

ComparativeEfficacy2129

Drug ACR20 ACR50 ACR70

Etanercept 65[71] 40[39] 21[15]

Infliximab [50] [27] [8]

Adalimumab 54 [73] 41 [62] 26 [46]

Certolizumab 46[59] 23[37] 6[21]

Golimumab [62] [40] [24]

Anakinra [34] [13] [3]

Abatacept 53[62] 16[32] 6[13]

Rituximab [51] [27] [12]

Tocilizumab [5156] [2532] [1113]

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BiologicDMARDCounseling2129

Maycauseheadacheorinjectionsitereactions

Useaseptictechniquewhenadministering Allowsolutiontoreachroomtemperature

Rotateinjectionsites

Donotrubtheinjectionsite

Reportsignsofinfectionoranemia

Avoidlivevaccineswhileontherapy

WhentoSwitch11

Inadequateresponseafter3months

o TraditionalDMARDso AntiTNFtherapies

o NonTNFbiologicDMARDs

o Hydroxychloroquine?

PleaseseeattachmentforcompleteACD

treatmentalgorithmforestablishedRA

RAPipeline31

398453

774 789

500

600

700

800

900

NumberofPipelineAgentsbyDiseaseState

4889

146 159186 205 217

266 277

0

100

200

300

400

RAPipeline31

NDAFiled,2 Undefined, 4

Phase

III,19

PhaseI,27

Statusof

RAPipeline

Agents

Approved,39

PreClinical,46

PhaseII,57

Terminated,72

RAPipeline:PhaseIIIAgents31

11orallydosed

4largemolecule

Agentsofinterest

,o Sarilumab(subQ,IL6inhibitor)

o Fostamatinib(oral,sykkinaseinhibitor)

RAPipeline:AgentswithNDA31

Tofacitinib

o Oral,5or10mgBID

o Januskinaseinhibitor

Ibuprofen+Famotidine

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PharmacistsRole3,30

Educationandcounseling

o Roleoftherapyandexpectationso Natureofthedisease

o Sideeffectmanagement,includinginfection

o Nonpharmacologictherapies

o Importanceofadherence

Monitoringeffectiveness

Providingorrecommendingvaccinations

References

Pleaserefertohandout.

Questions

Mike Crowe, PharmD

Clinical Pharmacist

Diplomat Specialty Pharmacy

Keeping Patients Healthier...Longer.

office: 810.768.9324

cell: 810.399.7589

fax: 810.282.0190

mcrowe@diplomatpharmacy.com

diplomatpharmacy.com

Question1

1. Whichofthefollowingisfalseregardingrheumatoid arthritis(RA)?

a. RAaffectsagreaterproportionofwomenthanmen.

b. RAgenerallyaffectsjointsinasymmetricalmanner.

c. RAoccursasaresultofafailureintheimmunesystem.

d. AllpatientsdiagnosedwithRAwilldeveloprheumatoidfactor.

e. Alloftheabovearetrue

Question2

2. WhichofthefollowingisnotadirecttargetofcurrentRAtherapy?

a. TNFalpha

b. Inflammatorycytokines

c. Blymphocyteproliferation

d. Tcellactivation

e. All

of

the

above

are

targets

of

current

RA

therapy

Question3

3 . Of thecounselingpointsbelowregardingprefilledsyringesofantiTNFagents,which

wouldbetheleastappropriate?

a. Itisrecommendedthatyouhavealcoholpads,cottonswabsandasharps

containeratthetimeofinjection

b. Toensureconsistency,shakethedevicewellpriortouse

c. Toreduce

injection

site

irritation,

you

may

allow

the

device

towarm

for

15

20

d. Keeprefrigerated; donotfreezethecontentsofthedevice

e. Keepingarecordofpreviouslyusedinjectionsitesmayhelpyouensurerotation

ofsites

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Question4

4. Whichdrugandsideeffectcombinationbelowisappropriatelymatched?

a. Leflunomide:visionchanges

b. Hydroxychloroquine:elevated

liver

enzymes

c. Sulfasalazine:changesintheurineandskincolor

d. Tocilizumab:reducedcholesterol

e. Noneoftheabove

Question5

5. Whichcounselingpoint(s)shouldallpatients receiveregardingthebiologicagents?

a. Rotateinjectionsites

b. Donot

inject

inareas

ofthe

skin

that

are

tender,

red,

bruised

orhardc. Themostcommonsideeffectisinjectionsitereaction

d. Reportanysignsofinfectiontoyourphysician

e. Alloftheabove

1987ACDDiagnosticCriteria

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MakeWayforRA:AnOverviewofRheumatoidArthritis MikeCrowe,Pharm.D.

References

1. McInnesIBandSchettG.Thepathogenesisofrheumatoidarthritis.N Engl J Med.2011;365:220519.2. MyasoedovaE,CrowsonCS,KremersHM,etal.Istheincidenceofrheumatoidarthritisrising?ResultsfromOlmsted

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