Principles of Therapeutics
Rheumatology · Principles of Therapeutics 🎯 Practice these cards
Prednisone at >____ mg/d for >____ months triggers a baseline osteoporosis risk assessment within 3–6 months.
Patients expected to receive prednisone >2.5 mg/d for >3 months need a baseline osteoporosis risk assessment within 3–6 months; those >40 or with risk factors get periodic BMD testing, and moderate-to-high fracture-risk patients get prophylactic antiresorptive therapy (preferably an oral bisphosphonate).
Methotrexate is dosed once ____ (frequency), 10–25 mg, with ____ acid co-therapy, and must be stopped ≥____ months before pregnancy.
Methotrexate is the first-line anchor DMARD for RA: 10–25 mg once WEEKLY (oral or SC; parenteral more reliable >15 mg), with folic acid co-therapy. Teratogenic and abortifacient — stop ≥3 months before conception. Monitor CBC, LFTs, creatinine; avoid in significant hepatic/renal disease.
The hydroxychloroquine dose ceiling to limit retinopathy is ≤____ mg/kg/day; 15-year retinopathy risk at that dose is about ____%.
Hydroxychloroquine is dosed ≤5 mg/kg/day (actual body weight) to limit retinal toxicity: 15-year cumulative retinopathy incidence was 2.7% at ≤5 mg/kg, 11.4% at 5–6 mg/kg, and 21.6% at >6 mg/kg (Melles 2023). Screening: baseline exam, then annual after 5 years. In SLE it reduces mortality and nephritis; in RA it does not slow radiographic progression.
After stopping leflunomide, a ____ washout is required before pregnancy because of its persistent teratogenic metabolite.
Leflunomide is extremely teratogenic with a very long-lived active metabolite: after discontinuation, cholestyramine washout (with drug-level confirmation) is required in all women of childbearing potential who wish to conceive.
Azathioprine causes severe myelosuppression in patients deficient in ____ enzyme, and must never be combined with xanthine oxidase inhibitors such as ____.
Azathioprine toxicity: severe myelosuppression in TPMT-deficient patients (check TPMT), and a contraindicated combination with xanthine oxidase inhibitors (allopurinol, febuxostat), which block its degradation.
The ORAL Surveillance trial found higher rates of ____ events and ____ with tofacitinib than TNF inhibitors in RA patients ≥50 with CV risk factors.
Tofacitinib (JAK1/3), baricitinib (JAK1/2), upadacitinib (selective JAK1): oral tsDMARDs with efficacy equal to biologics. Risks: zoster reactivation (more than biologics), hyperlipidemia, cytopenias, hepatotoxicity, thrombosis — and per ORAL Surveillance, higher MACE/malignancy vs TNF inhibitors in at-risk patients, prompting FDA boxed warnings and EULAR preference for bDMARDs when CV/malignancy risk factors exist.
Patients on biologics or JAK inhibitors must not receive ____ attenuated vaccines; screening before initiation includes TB, ____, HCV, and HIV.
Before biologics/JAK inhibitors: screen for latent TB (TST or IGRA; annually if exposure risk), HBV, HCV, and HIV; treat latent/active infection first. Update vaccines 2–4 weeks ahead. NO live attenuated vaccines on biologics or JAK inhibitors; inactivated and recombinant vaccines are fine. TNF inhibitors carry the highest TB reactivation risk.
Allopurinol should be initiated at ____ mg/d (____ mg/d in CKD 4–5) and titrated to target; the feared hypersensitivity reaction is ____.
Allopurinol: first-line urate-lowering agent. Start 100 mg/d (50 mg/d in CKD stage 4–5), titrate by 100 mg to target (approved up to 800 mg/d). Major risk: DRESS/DIHS — risk factors CKD, diuretics, and HLA-B*58:01 (screen Black, Han Chinese, Thai, Korean patients). Never combine with purine analogues.
ACR/EULAR remission requires tender and swollen joint counts each ≤1, CRP ≤____ mg/dL, patient global ≤1 — or an SDAI score ≤____.
Provisional remission: tender joint count ≤1, swollen joint count ≤1, CRP ≤1 mg/dL, and patient global assessment ≤1 (0–10) — OR SDAI ≤3.3. Treat-to-target aims for this state; in sustained remission, taper DMARD doses but do not stop them (2025 EULAR).
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