5 - Arthritis And Gout

Question 1

Herbenden Nodes, PIP’s and DIP’s affected, think:

Answer 1

Osteoarthritis

Question 2

APAP - MOA (for OA):

Answer 2

No significant anti-inflammatory effect

Acts centrally as an analgesic and antipyretic

Question 3

APAP - clinical use in OA:

Answer 3

1st line for pain management of OA

Efficacy - similar pain relief to NSAID, less ADR’s

Question 4

NSAID’s - clinical use in OA:

Answer 4

Anti-inflammatory and analgesic

Lower doses for analgesia, higher doses for inflammation

Question 5

Topical NSAID’s for OA - who uses it

Answer 5

Knee-only arthritis

Question 6

What is Diclofenac Gel 1%?

Answer 6

Topical NSAID for knee or hand osteoarthritis

Question 7

Topical Salicylates (Bengay, Adpercreme, etc) for OA - MOA?

Answer 7

Local inhibition of COX-2 enzymes

Question 8

Capsaicin in OA - MOA?

Answer 8

Releases and immediately depletes substance P from afferent nociceptive nerve fibers

Question 9

Caspaicin - clinical use:

Answer 9

Muscle/joint pain

Neuropathic pain associated with diabetes or postherpatic neuralgia

Must use regularly 4x a day for maximum effect

Question 10

Intra-articular corticosteroids - MOA:

Answer 10

decreases inflammation by suppression of

migration of polymorphonuclear leukocytes and reversal of increased capillary permeability

Question 11

Intra-articular corticosteroids - clinical use:

Answer 11

OA/RA

Not to exceed 3 to 4 injections per year (significant degradation of cartilage)

Question 12

Hyaluronate Injections - proposed MOA:

Answer 12

Hyaluronic acid is a viscous substance in synovial fluid that lubricates the joint

Question 13

Hyaluronic injection - clinical use:

Answer 13

Not generally recommended

May try in patients who fail other therapies

Question 14

Opioids for OA - for pt’s who:

Answer 14

Get no relief from APAP, NSAID’s, or topical therapy

Question 15

Tramadol (Ultram) C-IV - MOA:

Answer 15

Partial Mu receptor agonist

Serotonin and norepinephrine reuptake inhibitor

Question 16

Tramadol - clinical use in OA:

Answer 16

Moderate to severe pain that is not controlled by NSAID’s or APAP

Pt’s who can’t take NSAIDS

Question 17

Tramadol - AE’s

Answer 17

Increased risk of serotonin syndrome

Question 18

What labs tests will be positive in RA?

Answer 18

Rheumatoid factor (RF)
Elevated C-reactive protein (CRP)
Elevated erythrocyte sedimentation rate (ESR)

Question 19

NSAID’s - use in RA?

Answer 19

Immediate relief of pain and inflammation

Preferred as ADJUNCT to DMARDs while they start to kick in

Question 20

Preferred NSAID’s for RA:

Answer 20

Ibuprofen
Meloxicam
Nabumetone
Naproxen

Question 21

Corticosteroids for RA?

Answer 21

Methylprednisolone IV
Prednisolone PO
Prednisone PO

Question 22

What are DMARDs?

Answer 22

Disease-Modifying Anti-Rheumatic Drugs

Takes weeks to months to see full benefit

Screen pt’s for Hep B/C and TB prior to starting therapy

Question 23

What are the four traditional DMARDs?

Answer 23

Methotrexate
Leflunomide
Hydroxychloroquine
Sulfasalazine

Question 24

What is the preferred DMARD to start with according to ACR?

Answer 24

Methotrexate

Question 25

Methotrexate - MOA?

Answer 25

Dihydrofolate reductase inhibitor Interferes with DNA synthesis Inhibits fast-growing cells Leads to anti-inflammatory and, unfortunately, IMMUNOSUPPRESSIVE effects

Question 26

Methotrexate - clinical use:

Answer 26

Preferred DMARD for RA tx Also tx’s joint symptoms of psoriatic arthritis

Question 27

Methotrexate - AE’s?

Answer 27

GI Leukopenia (keep an eye on CBC, platelets), hepatic cirrhosis (keep an eye on AST/ALT)

Question 28

Methotrexate - pregnancy cat?

Answer 28

X

Question 29

What is the methotrexate toxicity reversal agent?

Answer 29

Leucovorin (supplies the necessary cofactor blocked by methotrexate)

Question 30

Leflunomide - MOA:

Answer 30

PRODRUG Inhibits pyrimidine synthesis Antiproliferative, anti-inflammatory

Question 31

Leflunomide - pharmacokinetics:

Answer 31

Detectable levels 2 years after stopping medication If you need to rapidly clear the drug you can use CHOLESTYRAMINE

Question 32

Leflunomide - AE’s?

Answer 32

Severe liver injury Peripheral neuropathy

Question 33

Leflunomide - pregnancy cat?

Answer 33

X

Question 34

Hydroxychloroquine - MOA:

Answer 34

Inhibits locomotion of neutrophils chemotaxis of eosinophils

Question 35

Hydroxychloroquine - clinical use:

Answer 35

Anti-malarial (only labelled use) RA and SLE (off-label)

Question 36

Sulfasalazine - MOA:

Answer 36

PRODRUG Cleaved by bacteria in the colon and 5-aminosalicylic acid Decreased production of IgA and IgM

Question 37

Sulfasalazine - clinical use:

Answer 37

Used for mild RA Not as effective as methotrexate Also used for ulcerative colitis

Question 38

Sulfasalazine - drug interactions

Answer 38

ABX can cause decreased absorption Sulfasalzine binds iron in the GI tract Can displace warfarin

Question 39

All biologic DMARD’s can increase risk of:

Answer 39

Infection

Question 40

Black box warning for biologic DMARD’s:

Answer 40

All anti-TNF-alpha can cause increased lymphoproliferative cancers in peds and adults

Question 41

Etanercept typically for pt’s who:

Answer 41

Have failed methotrexate

Question 42

MOA for biologic DMARD’s:

Answer 42

Block the pro-inflammatory cytokines TNFa, interleukin, or bind on target receptors on T-cells to prevent the co-stimulation needed to fully activate T-cells

Question 43

Predisposing factors for gout:

Answer 43

1. Diet - meat, fatty food, alcohol, high-fructose | 2. Medical - DM, HTN, HLP

Question 44

What is the serum urate target in tx of gout:

Answer 44

6mg/mL

Question 45

Non-pharm management of gout:

Answer 45

``` Weight loss Healthy diet Exercise Smoking cessation Adequate hydration ```

Question 46

3 primary classes of meds for acute gout:

Answer 46

NSAID’s Colchicine Glucocorticoids

Question 47

What are the three primary med classes for urate-lowering (chronic suppression):

Answer 47

1. Xanthine Oxidase Inhibitors 2. Uricosuric agents 3. Uricase

Question 48

Most appropriate first-line drugs for acute gout attack?

Answer 48

NSAID’s and Colchicine

Question 49

Colchicine only if initiated within ___ hours of attack onset

Answer 49

36

Question 50

NSAID’s plus corticosteroids are NOT recommended in acute gout due to:

Answer 50

GI ADE’s

Question 51

Which NSAID’S are FDA approved for gout?

Answer 51

Naproxen Indomethacin Sulindac

Question 52

Colchicine - MOA:

Answer 52

Binds to intracellular protein tubulin; prevents activation, degranulation, and migration of neutrophils associated with mediating some gout symptoms

Question 53

Colchicine - clinical use:

Answer 53

Treatment of gout flares | Prophylaxis of gout flares

Question 54

Colchicine - drug interactions?

Answer 54

Significant - CYP3A4

Question 55

Urate-Lowering Therapy (ULT) - clinical use:

Answer 55

Chronic management of hyperuricemia Tophi present Two or more attacks per year CKD Past urolithiasis

Question 56

What is the first-line ULT?

Answer 56

Xanthine Oxidase Inhibitor - Allopurinol or Febuxostat

Question 57

XOI - MOA:

Answer 57

Inhibits uric acid synthesis by inhibiting xanthine oxidase (therefore no conversion to uric acid)

Question 58

Which XOI has a higher risk of thromboembolic events?

Answer 58

Febuxostat

Question 59

Uricosuric Agents - MOA:

Answer 59

Weak organic acids that promote renal clearance of uric acid by inhibiting proximal tubule urate-anion exchangers that mediate urate reabsorption In english -> stop reabsorption of urate

Question 60

What type of meds are Probenecid and Lesinurad?

Answer 60

Uricosuric Agents

Question 61

What type of meds of Pegloticase and Rasburicase?

Answer 61

Uricase

Question 62

Uricase - MOA:

Answer 62

It’s an enzyme that humans don’t normally have Lowers serum uric acid

Question 63

Clinical use of uricase:

Answer 63

Severe gout disease refractory to traditional ULT’s

Question 64

What can uricase exacerbate?

Answer 64

HF

Question 65

What is uricase contraindicated in?

Answer 65

G6PD deficiency