Arthritis Flashcards
what is another name for osteoarthritis (OA)?
Degenerative joint Disease (DJD)
RIsk factors for OA?
Age (>65) Gender (women) Obesity Activities w/ repetitive motion Genetics Race (black women) Osteoporosis
there may be an inverse relationship associated between OA and what?
osteoporosis
failure of the cartilage in the absence of any known underlying predisposing factor
Primary (idiopathic) osteoarthritis
is OA considered an inflammatory condition?
No
OA that occurs due to other disease states or trauma, i.e. metabolic or endocrine disorders or congenital factors
Secondary osteoarthritis
when is pain relieved w/ OA?
rest or removal of weight from joint, but as condition worsens pain may not be relieved by rest
how long does stiffness last w/ OA?
less than 30 minutes
what joints are most often affected in idiopathic oA?
DIP and PIP of hand First carpometacarpal joint knees hips cervical and lumbar spine first metatarsophalangeal MTP joint of toe
are there specific lab findings w/ OA?
No
bony enlargements (osteophytes) of the DIP joints. usually develop slowly, nonpainful, lateral and medial aspects of joint.
heberden’s nodes
bony enlargements of the PIP joints.
Bouchard’s nodes
what are some non-drug treatments w/ OA?
rest PT ROM muscle strengthening assistive devices diet- weight loss
what is the goal of drug therapy w/ OA?
relieve pain and inflammation
does OA drug therapy stop the progression of OA?
No, just treats where they are at
what analgesics are given for OA?
Tylenol/ NSAIDs topical capsaicin gluconsamine/ chondroitin intra-articular injection opioids
what intra-articular injections are available for OA?
corticosteroids
viscosupplementation- hyaluronic acid
No more than how many grams of tylenol per day?
3 grams/ day
what Inhibits release of substance P in peripheral nerves
topical capsaicin
when does topical capsaicin reach maximal efficacy?
after 2-4 weeks
Prepared from shells of crabs and other crustaceans
Substrate for production of articular cartilage
Glucosamine
how long does it take for symptoms to improve w/ glucosamine?
4-8 weeks
Prepared from bovine or porcine cartilage sources, takes longer than NSAIDs
Chonroitin sulfate
what steroids are used for OA (especially in knee)?
triamcinolone acetonide
methylprednisolone
what is the limit of corticosteroid injections in OA?
3-4 times per year
are oral corticosteroids recommended in OA?
No
what is a Naturally occurring glycosaminoglycan
that acts as a lubricants for the joint and helps replace the missing cartilage.
hyaluronic acid (HA)
what narcotics are used for OA?
propoxyphene
codeine/ oxycodone/ hydrocodone
is a chronic systemic inflammatory disease of the joints and related structures.
Rheumatoid Arthritis
what does RA attack?
Attacks the synovium and other vital organs and tissues
Eyes, heart, kidneys, blood vessels, and RBCs
prior to joint involvement, what will patients with RA experience?
prodromal symptoms- fever, fatigue, weakness, anorexia, joint pain, etc
when is RA the worse, and what improves it?
worse in the morning, improves w/ activity
What joints are most often involved in RA?
hands
wrist
feet
are joints warm with RA?
yes, but not as warm as w/ gout
what are some extra-articular involvements of RA
Anemia vasculitis pulmonary complications cardiac ocular (decrease tear formation)
what is a syndrome with Splenomegaly, neutropenia, and thrombocytopenia associated w/ RA
Felty’s syndrome
Non-pharm treatments for RA
Rest, OT, PT, assistive devices
Weight reduction or management
Splinting, joint protection
What does DMARD stand for?
disease modifying anti-rheumatic drugs
when should you start DMARDs
within 3 months, selected based on specific issues
what are nonbiologics DMARDs
Hydroxychloroquine Methotrexate Sulfasalazine Leflunomide Minocycline
What are Non-TNF biologics DMARDs
Abatacept
Rituximab
Tociluzimab
what are anti-TNF biologics DMARDs
Etanercept Adalimumab Infliximab Golimumab Certolizumab pegol
With low disease activity, what should you start with?
Non-biologic medication
monotherapy
With moderate disease activity and poor prognosis what therapy do you do?
Combine different DMARDs from different categories
When do you start to add the anti-TNF and combo therapy
very progressed dz state
what was hydroxychloroquine originally used for?
antimalarial medication
First line option, weaker DMARD, good for a person w/ minimal symptoms. Can cause retinal toxicity.
hydroxychloroquine
how often do you ahve to do an opthalmologic exam w/ hydroxychloroquine?
twice yearly
does hydroxychloroquine cause liver, kidney or bone toxicities?
No
what is the onset of hydroxychloroquine?
2-6 months
ADRS w/ hydroxychloroquine
ocular toxicity
N/V/D (take w/ food)
derm- pruritis, rash, alopecia, increase pigmentation
neuro- HA, insomnia, vertigo
Who is hydroxychloroquine C/I in?
significant visual, hepatic, or renal impairment
Mainstay of therapy for patients not responding adequately to NSAIDS (moderate to severe RA). Need to replace folic acid w/ this med. best long term outcome of the DMRDs
Methrotrexate
Time of onset w/ methotrexate
2 weeks - 2 months (max effect w/i 4-8 weeks)
what mortality does methotrexate reduce?
CV morality
ADRs w/ methotrexate
hematologic-thrombocytopenia, leukopenia (dose related)
stomatitis (and GI effect) - dose related
pulmonary fibrosis, pneumonitis
elevated liver enzymes
NSAIDS may ______ methotrexate clearance and increase ADRs
decrease
what is an antidote for methotrexate toxicity?
Leucovorin (folic acid derivative)
what do you need to monitor w/ methotrexate? (every 1-2 months)
LFTS, CBC, total bilirubin
Hep B and C
serum creatinine, albumin
Prodrug cleaved by bacteria in the colon into sulfapyradine and 5-aminosalicylic acid. treatment for mild RA or in combination
Sulfasalazine
what should be monitored w/ sulfasalazine
CBC then q week for 1 month then q 1-2 months
ADRs w/ sulfasalazine
lot of GI effects
HA
threatening rxs- d/c if this happens
(don’t use w/ sulfa allergy)
Reversible inhibitor of DHODH interferes with RNA and DNA synthesis in lynphocytes
Reduces pain and inflammation w/ RA, slows structural damage
Leflunomide
ADRs w/ Leflunomide
alopecia, rash
caution w/ liver dz
what to monitor w/ Leflunomide
CBC and LFTs monthly
pregnancy category w/ Leflunomide
X
what washout must you do if a person has been on Leflunomide and wants to get pregnant
cholestyramine
Soluble TNF receptor that competitively binds 2 TNF molecules rendering inactive
Additive effects when in combination with methotrexate
Etanercept
Anti-TNF-alpha monoclonal Antibody (IgG)
Inhibits progression of structural damage
Infliximab and adalimumab
what test do you need to get before starting biologics- TNF antagonist
tuberculin skin test
what biolocis- TNF antagonists must be combined w/ methotrexate?
infliximab
ADRs w/ infliximab
infusion rxn (pre treat w/ tylenol)
ADRs of TNF antagonists
worsening of infectious complications
worsen heart failure
lupus-like syndromes, hepatotoxicity
may exacerbate MS
IL-1 receptor antagonist used in moderate to severe RA. monotherapy and combo w/ MTX
Anakinra
what monitoring is needed for Anakinra
none
ADRs w/ Anakinra
injection site rxns
don’t use in combo w/ TNF antagonists
what is Anakinra use reserved for?
failure after TNF antagonists
Biologic medication- Inhibits T lymphocyte activation, used as monotherapy or w/ combo. soluble fusion protein.
Used for moderate- severe or refractory RA
Super expensive
Abtacept
Depletes B lymphocytes, reducing antibody formation
Used in combo w/ MTX for moderate- severe RA w/ inadequate response to TNF antagonsits
Rituximab
ROA for rituximab
IV infusion separated by 2 weeks
premedicate w/ methylprenisolone
what drugs can you give for symptoms relief w/ RA
NSAIDS oral prednisone (<10 mg/ day) intrarticular injection of glucocorticoids opioids surgical tx
what are corticosteroids used for w/ RA
bridge to control debilitating symptoms until DMARDs take effect
Metabolic disorder characterized by high levels of uric acid in blood
Gout
what drug interferes w/ uric acid synthesis (gout)
allopurinol
what increases uric acid excretion (gout) by inhibiting resorption of urate at proximal convoluted tubule
probenecid or sulfinpyrazone
inhibits leukocyte entry into affect joing (gout)
Reduction of pain and inflammation w/in 12 hours of administration
cholchicine
ADRs w/ colchicine
N/V/D
can give it until you have GI side effects
used for short term (don’t start other therapy until 3 days after)
NSAID primarily used in Gout
Indomethacin
ADRs w/ NSAIDS
HA
Dizziness
Risk of GI bleed
upset stomach
ADRS w/ indomethacin
may aggravate depression or other CNS disturbances, epilepsy and parkinsonism.
What drugs are C/I w/ gout due to inhibiting uric acid secretion in urine.
Aspirin and other salicylates
how to prevent gout attacks
avoid heavy alcohol use
avoid foods rich in purines
weight loss
what foods are rich in purines
fish poultry meat concentrated sweets rich pastries fried foods
is allopurinol used in an acute gout attack?
No
indications for allopurinol
Hyperuricemia of gout
Pts. w/allergy to uricosuric agents (probenecid, sulfinpyrazone)
Recurrent renal stones
ADRs w/ allopurinol
GI side effects
jaundice, liver problems
acute exacerbation of gout
Drug intreactions w/ allopurinol
Allopurinol interferes with metabolism of 6-mercaptopurine (anticancer agent) and
azathioprine
when can you start probenecid and sulfinpyrazone?
after a gouty attack has subsided
ADRs w/ probenecid
Ha, dizziness
GI side effects
uric acid stone (kidney stones)
exacerbation of gout
what does probenecid block serction of?
PCN
what does probenecid inhibit the excretion of?
naproxen, ketoprofen, and indomethacin
probenecid and what have an additive effect?
sulfinpyrazone
salicylate inhibit uricosuric effects of what?
probenecid and sulfinpyrazone
