Anti-Rheumatic Drugs

• RA – chronic immunologic disease

– Inflammatory changes in joints
– Pain
– Stiffness
– Reduced mobility
– Shortened longevity
 Objectives of Therapy
• Reduce pain, inflammation and stiffness

• Maintain joint function and range of motion

• Minimize systemic involvement

• Delay disease progression

 Treatment protocol
• Old: • New:

• NSAID • DMARD within 3

• Add a DMARD month of diagnosis
• Add a glucocorticoid • + NSAID
 Medications
• NSAIDS – relieve symptoms but do not
delay disease progression
– First Gen NSAIDS – ibuprofen, naproxen,
diclofenac, etc
– 2nd Gen NSAIDS – celecoxib (Cox2 Inhibitor)
• Glucocorticoids – decrease inflammation
• DMARDS – delay disease progression
and reduce joint injury
 Disease
Modifying Anti-
Rheumatic Drugs
 Drug Therapy
• Shot- acting anti-rheumatic drugs
– Gold compounds, penicillamine, azathioprine
• Long-acting
– methotrexate
• Diseas Modifying Anti-Arthritic Drugs
Biologic and non-biologic modifiers
– Adlimumab - etanercept
– Infliximab - leflunomide
 Common Biologic DMARDS
• TNF Antagonist – suppresses
inflammation by neutralizing TNF
– Etanercept (Enbrel)
– Adalimumab (Humira)
– Infliximab (Remicade)
– Certolizumab pegol ( Cimzia)
– Golimumab ( Simponi)
 Biologic DMARDS
• T-cell Activator Inhibitor
– Prevents activation of T-cells
– Abatacept (Orencia)
 B-lymphocyte depleting agent
 Decreases circulating B-lymphocytes by binding to
CD20 on B-cells  complex attacked by the
immune system  lysis and death of cells
 Rituximab ( Rituxan)
 Uses of DMARDs
• Relieve pain, inflammation, stiffness and
swelling of joints
• Slow or arrest the progression of
rheumatoid arthritis
• take 6 weeks to 6 months to produce
improvement
 Biological Response Modifiers

• Inhibit steps in inflammation by blocking

TNF (Tumor Necrosis Factor)
• TNF is secreted by macrophages,
leukocytes and fibroblasts  over time
cause synovium tobe inflammed 
granulation tissue erosion of cartilage
and bone in the joints
 Primary adverse effects

• Infection from depression of the normal

function of TNF in the natural immune
response and inflammatory process

• Increased incidence of lymphoma

• hepatotoxicity
 Preparations
• Adlimumab (Humira)
– 40 mg q 1-2 wks SC
– Adverse: serious infections, sepsis,
hypersensitivity, pneumonia, lymphoma
– Do not refrigerate med
– Monitor for both therapeutic and adverse
effects
• Etanercept (Enbrel)

– A: 25 g 2x weekly SC
– P: .4 mg 2x weekly
– Adverse: injection site reactions,
gastrointestinal distress, serious infections
– Reconstitute with 1 ml sterile water
– Refrigerate med
• Infliximab (Remicade)
– First line of treatment for moderate to severe
RA
– A: 3 mg/kg IV at 2, 6 weeks and q 8 wks
thereafter
– Adverse: hypersensitivity & serious infections’
– Evaluate for latent TB
– Monitor IV site
– Dilute reconstituted dose in 250 ml 0f 0.9%
normal saline
• Leflunomide ( Arava)

– Loading dose of 100 mg/day oral

– Adverse: Serious infections, hepatotoxicity,
anemia, diabetes mellitus
– Monitor liver studies
– May be taken with or without food
 Rapid acting Agents
• Methotrexate (Rheumatrex, Trexall)
• Cytotoxic immunosuppressant
– 7.5 mg per week orally
– Adverse: serious infections, mucositis, gastic
irritation, alopecia
– Associated with significant liver toxicity in
long-term treatment
– Take tablets at bedtime with an antacid
– Avoid alcohol and saliciylates
 Slow-acting
• Gold sodium thiomalate (Myochrisine)
– One dose weekly. Week 1 10 mg IM; week2 and
3 - 25 mg; 5o mg thereafter until a total dose of .8
g - 1 g has been given
– Adverse: dermatitis, renal damage,
hypersensitivity, irritated tongue, may worsen
CHF, diabetes, hepatitis
– Inject deep IM
– Urinalysis for proteinuria, hematuria
– Monitor hematological status observe for
dermatitis and stomatitis
– Vasomotor response may occur within 10
minutes
• Auronofin ((Ridaura)
– Orally, 3 mg bid or 6 mg tid, may increase to
9 mg/day
– SE: diarrhea, gastointestinal distress,
pruritus, nausea
– Monitor for development of
thrombocytopenia,lelukopenia
– Not for use in children
• Hydrochloriquine sulfate
(Plaquenil sulfate)
Anti-malarial agent
- 200-400 mg PO daily
- GI distress, ocular changes, hepatoxicity,
dermatological disorders
Give with milk or meals breakfast and dinner
Children more likely to develop toxic effects
than adults
Do not give to patients with psoriasis, may
precipitate attack
• Penicillamine (Cuprimine, Depen)
• Chelating agent –reduces titer or RF
– Initially 125-250 mg daily PO; increase daily
by 125-250 mg at 1-3 month intervals
– Maintenance: 500-750 mg daily
– SE: GI distress, loss of taste perception,
hematological disturbances, proteinuria, skin
rash, tinnitus
– Administer on an empty stomach with water
– Observe for skin rash, bruises, sore throat,
fever and other signs of serious hematological
effects
 Other nursing responsibilities
• Assesr forpain and range of motion
throughout therapy
• Monitor cbc fpr signs of bone marow
suppression
• Liver enzyme tests
• BUN and creatinine
• Gold preparations deep IM. Let pt lie down
for 30 mins after
• Keep gold meds in tightly closed container
• Do not administer gold preps that ae
darker than pale yellow
• Refer immediately patients on gold prep
who develop mouth ulcers
• periodic eye exams - antimalarials
• Fever in chelating agents – allergy
• Avoid sun exposure - photosensitivity