1. Rheumatology Board Review Accessory Handout

2. DMARDDosageOnset of Effect Adverse EventsMonitoring Auranofin (Ridaura)3-6 mg QD4-6 monthsDiarrheaCBC, urinalysis (u/a) every 3 months Azathioprine (Imuran)50-150 mg QD2-3 monthsGI intolerance, cytopenia, hepatitis infections, CBC, LFTs every 2-4 weeks initially, then every 2-3 months Cyclosporine (Gengraf, Neoral, generic) 2.5-5 mg QD2-3 monthsGI intolerance, cytopenia, infections, hypertension, renal disease Creatinine (Cr) every two weeks until dose is stable, then monthly; consider CBC, LFTs, and K+ level tests D-Penicillamine (Cuprimine) 250-750 mg QD3-6 monthsGI intolerance, skin rash, proteinuria, Rare: cytopenia CBC- u/a every 2 weeks until dose is stable, then every 2-3 months Hydroxychloroquine (Plaquenil) 200-400 mg QD2-6 monthsGI intolerance, Retinal toxicityEye examinations every 12 months IM Gold sodium thiomalate (Myochrysine) Aurothioglucose (Solganal) 25-50 mg IM every 2-4 weeks 6-8 weeksGI intolerance, skin rash, oral ulcers, proteinuria, cytopenia, CBC and u/a every 2 weeks until dose is stable, then with each injection Leflunomide (Arava)20 mg QD4-12 weeksGI intolerance, skin rash, hepatitis, cytopenia, highly teratogenic Hepatitis B and C serology in high- risk patients; CBC, Cr and LFTs monthly for 6 months, then 1-2 months; adjust dose or stop if LFTs elevated Methotrexate15-25 mg orally, sc or IM every week 1-2 monthsGI intolerance, oral ulcers, alopecia, hepatitis, pneumonitis, cytopenia, rash, teratogenic CBC, Cr and LFTs monthly for 6 months, then every 1-2 months; adjust dose or stop if LFTs elevated Minocycline (Minocin)100 mg BID1-3 monthsDizziness, skin pigmentationnone Sulfasalazine (Azulfidine)2-3 gm/day1-3 monthsGI intolerance, oral ulcers, cytopenia, rash CBC every 2-3 months

3. Biologic DrugsDosageOnset of Effect Adverse EventsMonitoring TNF Blockers Adalimumab (Humira)40 mg sc EOW2-12 weeksInjection site reaction (ISR), infection risk, TB reactivation Rare: demyelinating disorders Monitor for TB, fungal and other infections; CBC and Liver panel (LFTs) at baseline and monthly; thereafter every 2-3 months Etanercept (Enbrel)25 mg sc twice/ week or 50 mg sc weekly 2-12 weeksISR, infection risk, TB reactivation Rare: demyelinating disorders Monitor for TB, fungal and other infections; CBC and LFTs at baseline and monthly; thereafter every 2- 3 months. Certolizumab- Cimzia200/400 mg sc EOW/monthly 2-12 weeksInjection site reaction (ISR), infection risk, TB reactivation Rare: demyelinating disorders Monitor for TB, fungal and other infections; CBC and Liver panel (LFTs) at baseline and monthly; thereafter every 2-3 months Golumimab (Simponi)50 mg sc monthly 2-12 weeksISR, infection risk, TB reactivation Rare: demyelinating disorders Monitor for TB, fungal and other infections; CBC and LFTs at baseline and monthly; thereafter every 2- 3 months. Infliximab (Remicade)3 mg/kg at weeks 0, 2 and 4 weeks, then every 8 weeks 2-12 weeksInfusion reactions, infection risk, TB reactivation Rare: demyelinating disorders Monitor-TB, fungal and other infections; CBC, Cr and LFTs at baseline and monthly; thereafter every 2- 3 months.

4. DrugDosageOnset of Effect Adverse EventsMonitoring Other Biologics Anakinra (Kineret) – IL -1 blocker100 mg sc QD4-12 weeksISR, leucopenia, Infections, Hypersensitivity CBC at baseline and every 3 months Abatacept(Orencia) – CTLA 4 Ig, Costimulator blockade 500-1000 mg (weight based) at 0, 2 and 4 weeks then every 4 weeks 2-12 weeksInfusion reactions, infection risk, sepsis, hypersensitivity, COPD exacerbation Monitor for TB, other infections; CBC and chemistry and LFTs at baseline and with each infusion Rituximab (Rituxan)- B-cell inhibitor1000 mg at 0 and 15 days 2-12 weeksInfusion reactions, infection risk, reactivation and new viral infections, respiratory difficulty, cytopenia Monitor for TB, other infections; CBC and chemistry and LFTs at baseline and 2 weeks; thereafter every 2-3 months Tocilizumab (Actemra)- IL-6 blocker4 mg/kg or 8 mg/kg (weight based) every 4 weeks 2-12 weeksInfusion reactions, infection risk, sepsis, cytopenia, hepatitis, hypersensitivity, Lipid abnormalities, GI perforation Monitor for TB, other infections; CBC and chemistry and LFTs at baseline and with each infusion Tofacitinib (XelJanz) – JAK Kinase inhibitorOral daily- 5 mg or 10 mg BID 8-12 weeksInfection risk, sepsis, cytopenias, hepatitis, hypersensitivity, GI perforation Monitor for TB, other infections; CBC and chemistry and LFTs at baseline and periodically. Cytolytic Agent Cyclophosphamide (Cytoxan)BSA based monthly infusion, Rare- Orally 50-100 mg/day 8-12 weeksInfection risk, sepsis, cytopenias, hepatitis, hypersensitivity, infertility, cystitis & long term risk of bladder cancer Monitor for TB, other infections; CBC and chemistry and LFTs at baseline and periodically. U/A peridically.

5. Autoantibodies

6. Systemic Sclerosis and related syndromes

8. Monoarthritis Monoarthralgi a Exclude Periarticular Disease Tendonitis, Bursitis, Bone lesion, Myofascial Pain, Sprain/Overuse, soft tissue infection, peri-articular GC infection Monarticular Arthritis/ Arthalgia Always consider Aspiration of joint for diagnosis Cell count, Crystals, Gram stain, Culture Crystalline disease Gout/pseudo gout True inflammatory changes in joint with urate or CPPD crystals on synovial fluid examination; cell count of 2000- 50,000; Cystic erosions (gout) or chondorcalcinosis (pseudgout) on X- ray Osteoarthritis/trauma Absence of inflammatory changes and <30 minutes AM stiffness with the presence of pain, crepitus, mild swelling, osteophytes; X-ray changes of joint narrowing, osteophytes formation, sclerosis; Joint fluid aspirate either bloody or cell count<2000; If diabetic, consider neuropathic joint Seronegative spondyloarthropathy Inflammatory changes of joint (particularly knee or ankle); Synovial fluid cell count of 2000- 50,000; involvement of eyes (conjunctivitis or uveitis) or back/sacroiliac joints with prolonged (>1 hour AM stiffness) Early onset inflammatory arthritis RA or SLE Inflammatory joint changes with other etiologies excluded; with prolonged (>1 hour AM stiffness); with positive RF or ANA Infection Gonococcus Staphylococcus Streptococcus Diagnostic features: True joint Inflammation with pain, swelling, erythema, Leukocytosis and fever, Synovial fluid cell count >50,000, Positive gram stain and culture

9. Inflammatory AM stiffness > 1 hour Joint erythema, swelling, or pain And Elevated ESR (must exclude other inflammatory diseases such as infection or cancer) Or Positive RF Positive ANA Implies a differential diagnosis of: Rheumatoid arthritis Connective tissue disease (lupus, PSS, PM/DM, Sjogren’s) Viral infection Seronegative spondyloarthropathy Sarcoidosis Non- Inflammatory AM stiffness < 1 hour No joint erythema, swelling and Normal ESR Negative RF or ANA Implies a differential diagnosis of Myofascial pain Fibromyalgia Osteoarthritis Endocrinopathy Pain syndrome Does not clearly fit into either category, Consider: Seronegative RA Seronegative spondyloarthropathy Polyarthritis/ Polyarthralgia Determine by History and Physical if inflammatory (Prolonged AM stiffness, erythema, swelling, warmth, pain) Evaluation dictated by history and physical may include CBC, urinalysis, liver and kidney function, RF, ANA, ANCA, ESR, TSH, CPK, HBA1C, CXR and regional/back/SI joint X-rays