DR Medhat MRCP

• Management of rheumatoid arthritis (NICE 2009):
Initial ttt of newly diagnosed active RA(combination of DMARDS + short course steroid)
i.e Methotrexate + another DMARD (e.g sulfasalazine) + short course steroids)
1) DMARDs (Disease Modifying Anti-Rheumatic Drugs )
Methotrexate Is the most widely used DMARD (see details later)
Sulfasalazine (salazopyrine®)
Leflunomide (Arava®) : -- mitochondrial dihydroorate dehydrogenase → - -
pyrimidine synthesis → -- expantion of autoimmune lymphocytes→ ↓ pain &
swelling. It`s hepatotoxic ,BM -- & contraindicated in pregnancy.
Monitoring of leflunomide : → ALT/AST/CBC monthly for 6 months
If stable → check 2 monthly thereafter.
If ALT/AST ↑ but ≤ 2 folds of upper normal→↓dose & recheck in 1 week
If CBC↓↓ & ALT/AST ≥ 3 folds upper normal→recheck after 72 hrs→ if
same→DC & washout using cholestyramin or activated charcoal (chelators).
Hydroxychloroquine
2) TNF-inhibitors
Indication : inadequate response to at least two DMARDs including methotrexate.
Infliximab Adalimumab Etanercept
- Monoclonal antibody
- S.C administration
- Monoclonal antibody
- Binds to TNF-α and prevents
it from binding with TNF
receptors
- I.V administration
- Risks→ reactivation of TB
3) Rituximab :
- Anti-CD20 monoclonal antibody, results in B-cell depletion
- Two of 1g I.V infusions are given two weeks apart.
- Infusion reactions are common.
Sulphasalazine (salazopyrine®) :
13
- Recombinant human
protein
- Acts as a decoy
receptor for TNF-α
- S.C administration
- Risk→ demyelination
& reactivation of TB.
• Side effects : B.M depression (pancytopenia),macrocytosis , hepatotoxicity ,azospermia
• Monitoring : WBCs < 3.5
A. CBC monthly for 3 months : → hold if Neutrophils < 2
Platelets < 150
→ if normal → Check CBC every 3 months X 1 year
B. LFT monthly for 3 months : → hold if ALT or AST ↑ ≥ double upper normal.
→ If normal → Check LFT every 3 months X 1 year