Arthritis Flashcards
Factors influencing management of RA
Level of disease - early use of DMARDs, DMARDs vs symptomatic relief
Stage of therapy
Regulatory restrictions
Patient preference
Symptomatic management of RA
Paracetamol
NSAIDs - in early mx or acute flare; selective (celecoxib) or non-selective (ibuprofen); bridges to DMARDs
Opioids - weak (codeine, tramadol) or strong (morphine, pethidine)
Glucocorticosteroids - anti-inflammatory and immunosuppressive effect; decrease inflammatory cytokines
Intra-articular steroids - methylprednisolone, betamethasone. Indicated when only a few joints are involved
DMARDs - arrest or slow progression of bone and cartilage destruction
Side effects of glucocorticosteroids
Occur with prolonged use of high doses
Can lead to cushings
Cause DM and HPT
Psychological: sleep disturbances, mood changes, psychosis
MSK: osteoporosis, myopathy, bone necrosis
Side effects of intra-articulate steroids
Crystal arthropathy
Skin atrophy
Pigment changes
Limited to 4 per year
Examples of DMARDs and duration of therapy
Methotrexate, chloroquine, sulfasalazine
Takes between 6/52 and 6/12 to see result therefore therapy must be continued up until then
Features of osteoarthritis
Advanced age
Different joint profile - cervical NS lumbar spine, 1st CMJ, DIP joint, hip, knee
Stiffness pattern
Exam: crepitus, bony enlargement, decreased ROM, malalignment, tenderness
Synovial fluid less active
Radiological features present
Pattern of presentation
Management of osteoarthritis
Non-drug measures: A. Physic B. Weight loss C. Braces and insoles D. Exercise E. Assistive devices F. Surgery
Drug measures: A. Paracetamol B. NSAIDs - avoid LT when possible C. Weak opioids D. Adjuvants (amitriptyline) E. Intra-articular steroids - when effusions or signs of inflammation
3 phases of gout
Acute gout
Inter critical period
Chronic tophaceous gout
Features of acute gout
Painful inflamed single joint Maximal pain between 12-24 hours Synovial fluid with - bifringent Hyperuricaemia may be absent Complete resolution of symptoms between attacks
Long term complications of gout
Urate crystal stones
Renal impairment
Management of acute gout
Treat the acute attack
Anti-inflammatories: NSAIDs, colchicine, corticosteroids
Management of inter critical and chronic gout
Objectives: prevent further attacks, prevent complications
Non-pharm mx: diet
Pharm mx:
A. Decrease uric acid production - xanthine oxidase inhibitors (allopurinol)
B. Improve uric acid excretion - probenecid
Methotrexate MOA
Methotrexate metabolized to polyglutamate (active)
Together inhibit key enzymes -> interferes with metabolic processes (carbon metabolism, purine synthesis and pyramidine synthesis) -> alters intracellular nucleotide pools and increases adenosine release -> antirheumatic effect
Methotrexate contraindications
Pre-existing blood dyscrasias Renal or hepatic disease Previous or existing herpes or varicella infections Serous effusions Pregnancy Lactation
Side effects of methotrexate
BM suppression
Mucosal ulceration
Hepatotoxicity
Nephropathy
Hyperuricaemia
Derm - alopecia, rash, pigmentation, urticaria
Other - headache, drowsiness, malaise, fatigue, blurred vision
Use of methotrexate in RA
Start slow and adjust dose as per response Folic acid supplemented with every dose Folinic acid rescue if complications No live vaccines while on methotrexate WOMCBP family planning
Drug interactions of methotrexate
NSAIDs, aspirin, probenecid - decrease clearance
Phenytoin, cotrimoxazole, trimethoprim - additive anti-folate activity
Sulfasalazine side effects
Nausea and vomiting
Headaches
Rashes
Can potentiation anti-folate activity of methotrexate and phenytoin
Rare: hemolytic anemia, neutropenia, methaemaglobinaemia, thrombocytopenia , reversible infertility in me
Use of sulfasalazine in RA
Slows radiological progression
Can be used with methotrexate
Is she during pregnancy
Contraindicated in patients with sulphur allergy
Primary use of chloroquine and use in RA
Primary use - anti-malarial
RA- may suppress T-lymphocyte response -> anti-inflammatory
Problems with use of chloroquine
Concentrates melanin-containing cells, including eyes -> irreversible retinal damage therefore require 6/12ly eye exams
Can cause haemolysis in G6PD deficiency
Mechanism of colchicine anti-inflammatory effect
Binds intracellular protein (Tubulin) -> prevents polymerization into microtubules and inhibits leukocyte migration and phagocytosis
Colchicine adverse effects and contraindications
Side effects:
A. Common- GI intolerance (nausea, vomiting, diarrhea, abdo pain)
B. Uncommon- alopecia
C. Rare- hypersensitivity, BM suppression, myopathy
Contraindications- renal impairment
Side effects of allopurinol
Common- hypersensitivity - can be fatal severe toxic syndrome in patients with renal failure
Uncommon- GI disturbances, drowsiness, headaches
Rare- BM suppression, peripheral neuropathy, arthralgias, myalgia, jaundice
When should colchicine and probenecid not be used and why
Not used in an acute attack or within 4/52 after
Can trigger an acute attack
MOA probenecid
Blocks URAT (uric acid reabsorption) -> uricosuria
Contraindications to and interactions of probenecid
Contraindications- renal stones, blood dyscrasias, GFR
Side effects of probenecid
Common- headaches, nausea, vomiting, flushing, dizziness, urinary frequency
Rare- anaplastic anemia if G6PD deficiency, nephrotic syndrome, hepatic necrosis, hypersensitivity reactions
Diagnostic criteria of rheumatoid arthritis
> 6/52: A. Morning stiffness B. Arthritis in >3 joint areas - common: MTP, MCP, PIP, wrist, elbow, knee, ankle C. Arthritis of hands D. Symmetric arthritis
Rheumatoid nodules
Serum rheumatoid factor
Radiographic changes
> 4= RA
