11: Pharmacology of arthritis Flashcards by Ross Wilson

Which drugs are used to treat arthritis?

Simple analgesics

NSAIDs

DMARDs

Steroids

Biologics

Specific treatments for gout

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What are adjuvant painkillers which can be added on to help control pain?

Opioids

Anti-depressants

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What are some NSAIDs used to treat arthritis?

Diclofenac

Ibuprofen

Naproxen

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What are some NSAID side effects which must be considered before putting an arthritis patient on them?

Peptic ulcers (loads of GI side effects)

Renal dysfunction

Increased CVD risk

Exacerbation of asthma

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Which kind of NSAID disproportionately increases CVD risk?

Cox-2 inhibitors

(-coxibs)

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What are DMARDs?

Disease modifying anti-rheumatic drugs

i.e drugs used alongside symptom controllers to alter the progression of the disease

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What DMARD should be started immediately in RA patients to stop the progression of their disease?

How long have you got (ideally) after symptoms start?

Methotrexate usually

3 months

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Apart from NSAIDs and DMARDs, which other drugs are used to treat inflammatory arthritis?

Steroids

Biologics

(+ stuff for gout)

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How long do DMARDs need to take effect?

What is used in the interim?

Weeks to months (e.g methotrexate - 6 weeks)

Steroids likely

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Do DMARDs have an analgesic effect?

No, purely anti-inflammatory to reduce rate of joint damage

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DMARDs tend to have systemic __ __.

side effects

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DMARDs are only used when the ___ outweighs the ___.

benefit > risk

This translates to almost all RA patients, to spare steroid side effects

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Apart from methotrexate, what are some other DMARDs used to reduce disease progression?

Sulfasalazine

Leflunomide

Hydroxychloroquine

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Patients on DMARDs like methotrexate must have their ___ tested regularly.

Why?

blood

Check for side effects

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Hydroxychloroquine is the first line treatment in what kind of MSK disease?

Connective tissue disease

e.g SLE

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What are some side effects of methotrexate?

GI - n/d, mouth ulcers, hepatitis

Haemo - leucopenia, thrombocytopenia

Resp - pneumonitis

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What is methotrexate usually changed to if a patient has side effects?

Leflunomide

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What is a major side effect of leflunomide, similar to methotrexate?

Teratogenicity

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Which skin condition can sulfasalazine cause?

Steven Johnsons syndrome

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Hydroxychloroquine is an add-on agent in ___ and a first line therapy in __ __ __.

connective tissue disease

What is a known permanent side effect of hydroxychloroquine?

Retinopathy - visual impairment

What are some old fashioned DMARDs?

Gold

Penicillamine

What is a common target of mechanism-based biologic agents?

TNF

B cells (bc they produce autoantibodies)

Interleukins

Are biologic agents available to all patients?

Patient has to fulfill loads of criteria and they’re very expensive

How do biologic agents tend to be given to patients?

**Injections** once every week / fortnight

What is TNF?

**Tumour necrosis factor** Pro-inflammatory cytokine

Which scoring system for RA is used to measure the severity of the disease?

**DAS28**

How high must a patient's DAS28 score be to qualify for biologics? What is the other criterion?

**\> 5.1** Have been on at least 2 different DMARDs already

What are some side effects of anti-TNF agents?

**Increased risk of _infection_** **Increased risk of _skin cancer_** **May reactivate _latent TB_**

Do anti-TNF therapies cause fetal abnormalities?

**No**

What does rituximab target?

**B cells** so can be used to treat any disease involving autoantibodies

Ustekinumab and secukinimab are biologics used exclusively for which type of arthritis?

**Psoriatic arthritis** | (+ Psoriasis)

What are the two aspects of gout treatment?

**Acutely** **Prophylactically** (to prevent it happening again)

Is allopurinol any good in an acute flare of gout?

**No**, may actually exacerbate symptoms

What is used to treat acute episodes of gout?

**NSAIDs** **Steroids** **Colchicine**

When should allopurinol be prescribed to a patient with a history of gout?

**2-3 weeks after acute episode** **To prevent recurrence**

When is gout prophylaxis indicated?

**2 episodes of gout in 6 months**

What type of drug is allopurinol / febuxostat?

**Xanthine oxidase inhibitor**

Which drug must be given in addition to allopurinol/febuxostat for gout prophylaxis?

**Whatever drug you used to treat the acute flare**

What is a known side effect of allopurinol?

**Vasculitis** presenting as a big rash

Which immunosuppressant drug, commonly used in SLE, interacts with allopurinol?

**Azathioprine**

What happens if allopurinol and azathioprine interact?

**Irreversible bone marrow suppression**

Why may allopurinol be contraindicated in a patient with gout? What would be given instead?

**Renal dysfunction** **Febuxostat**

What are some steroid side effects?

**Loss of bone density** (osteoporosis) **Contribute to development of diabetes** **Weight gain** **Muscle atrophy** **Moon face** (Cushings appearance) loads of others

If a lupus patient complains of hip pain and they are on steroids, what should be suspected?

**Avascular necrosis of femoral head**

If possible, steroids should be used for as **(brief / long)** a period as possible.

**brief period**

How long should women come off methotrexate for before trying to conceive?

**3 months**

Which alternatives to methotrexates are safe in pregnancy?

**Sulfasalazine** **Hydroxychloroquine**

RA often ___ during pregnancy.

**improves**