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Exam 2-MSK > Arthritis > Flashcards

Arthritis Flashcards

1
Q

Gout/Hyperuricemia

Drug Options

A 
Allopurinol (Zyloprim)
Colchicine (Colcrys)
Febuxostat (Uloric)
Probenecid (Benemid)
Rasburicase (Elitek)
Pegloticase (Krystexxa)
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2
Q

Tx for Chronic Gout

A

Xanthine Oxidase Inhibitors: decrease of urimic acids

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3
Q

Allopurinol (Zyloprim)

A

MOA: Xanthine Oxidase inhibitor; Purine analog;
Reduces production of uric acids
Indications: primary or secondary gout (chronic Tx); chemo pts @ risk of tumor lysis syndrome (hematologic malignancies); recurrent calcium oxalate stones
NOT for asym hyperuricemia
-aids in dissolution of tophi, prevents dev or prog of chronic gout, decrease risk of perm renal damage
DI: Azathioprine, 6-mercaptopurine (inh enxymatic inactivation, reduce dose); Warfarin; theophylline
ADRs: rash (D/C imm), SJS, D/N, inc LFTs, acute gout attack (give colchicine or NSAID to settle flare)

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4
Q

Probenecid (Benemid)

A

MOA: blocks renal tubular reabsorption of urate (inc uric acid excrete, lowers serum urate levels); inhib PCN secretion (boost PCN levels)
Ind: hyperuricemia w/ gout (Chronic Tx) [alt med]
adj to PCN and ampicillin
ADRs: HA, N, worse gout flare, dizzy, uric acid kid stones, blood dyscrasias

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5
Q

Febuxostat (Uloric)

A

MOA: xantine oxidase inhibitor
Ind: chronic Tx
Caution: higher rate of CV events, hepatic failure (monitor LFTs)

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6
Q

Lensinurad (Zurampic)

A

MOA: blocks uric acid reabsorption
Ind: adj therapy with an XOI (not on guidelines yet)
Met: p450 2C9, induce 3A4
DI: p450 reduce efficacy of amlopdipine, sildenafil
ADRs: increase sCr, renal failure, kidney stones, HA, flu, GERD

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7
Q

Uric Acid Lowering Agents

Med Names

A

Colchicine (Colcrys)
Pegloticase (Krystexxa)
Rasburicase (Elitek)

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8
Q

Colchicine (Colcrys)

A

MOA: not well known, inhibits microtubule formation in bone cells and prevents neutrophil activation
Ind: prophylaxis and Tx of acute gout flares; familial Mediterranean Fever
ADRs: DIARRHEA!!!; throat pain
Met: PGP and CYP3A4 sub
CI: strong 3A4 inhibitors
Caution: narrow therapeutic window; blood dyscrasias, neuromusc toxicity, rhabdomyolysis,
Renal adjust

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9
Q

Pegloticase (Krystexxa)

A

MOA: catalyzes oxidation of uric acid to allantoin (inert H20 soluble molecule that’s renally excreted)
Ind: refractory chronic gout
Given IV due to risk of anaphylaxis and infusion rxn + premed with antihistamines and corticosteroids

ADRs: gout flare, infusion reaction, nausea, ecchymosis, nasopharyngitis, constipation, chest pain, vomiting, CHF exacerbation

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10
Q

Rasburicase (Elitek)

-just recog. and know what it’s for

A

Ind: hyperuricemia due to tumor lysis
ADRs: anaphylaxis, hemolysis, methemoglobinemia

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11
Q

Hyperuricemia/Chronic Gout

A
  • -The first-line pharmacological ULT in gout is XOI therapy with either allopurinol or febuxostat.
  • Patient education regarding diet, lifestyle, treatment objectives, and management of comorbid conditions is a core therapeutic measure for gout and for hyperuricemia.
  • -Target serum urate level should be lower than 6 mg/dL, and often lower than 5 mg/dL, to maintain improvements in gout signs and symptoms.
  • -The starting dosage of allopurinol should not exceed 100 mg/day (or less in moderate to severe CKD). This should be gradually titrated upward.
  • -Even in patients with CKD, the maintenance dose of allopurinol can exceed 300 mg daily.
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12
Q

Hyperuricenmia/Gout

–prior to starting allopurinol

A

Due to risk of severe allergic rxn:
test for HLA-B*5801 in
high risk groups: asians of Han Chinese and Thai descent

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13
Q

Rheumatologic agents

A

Systemic corticosteroids

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14
Q

Systemic corticosteroids

A 
Meds: 
Prednisone (Deltasone);
Methylprednisolone (Medrol);
Prednisolone 
MOA: Inhibit cytokine production, adhesion, protein activation, inflammatory cell migration and activation; Anti-inflammatory agents

Ind:
Asthma (short term to gain control; long term Sx prevention in severe persistent) [lowest effective dose for shortest duration];

life-long/low-dose for RA

ADRs:
short term: Hyperglycemia, increased appetite, fluid retention, wt gain, mood alteration, hypertension, peptic ulcer
Long term: Adrenal axis suppression; Growth suppression; Thinning of skin; Osteoporosis, HTN,
Diabetes, Cushing’s syndrome, Impaired immune function

MUST taper to take them off (to help with adrenals) and some will never come off it
**bone density tests MUST be done; age independent

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15
Q

DMARDs for Rheumatoid Arthritis

A 
DMARDs: 
Methotrexate
Leflunomide
Hydroxychloroquine
Sulfasalazine
Minocycline

Biologics:
Anti-TNF
Adalimumab, certolizumab pegol, etanercept, infliximab, golimumab

Non-TNF biologics:
Abatacept, rituximab, tocilizumab

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16
Q

Methotrexate (Rheumatrex, Trexall)

A

MOA: folate analog, inhibits dihydrofolate reductase (DHFR); interferes w/ DNA synthesis, repair, and replication;

Use: 1st line RA; relieves inflammation, swelling and pain; revents dz progression and joint destruction; psoriasis, cancers

ADRs: N/V, hair loss, skin rash, abn liver enzymes*, fatigue, mouth sores, diarrhea, low blood counts (inc infxn risk)

CI: pregnancy [teratogenic both male and female (wait 3 months for male, women one month] and lactation; liver dz/alcoholism; blood dyscrasias
Renal elim.

17
Q

Leflunomide (Arava)

A

MOA: pyrimidine synthesis inhibitor (enz block); anti-inflam; prodrug

Ind: reduce S/Sx, inhibit structural damage as evidenced by x-ray erosions and joint space narrowing and improve phys fxn in RA pts

ADRs: Diarrhea (20%); N/ stomach pain, indigestion, rash, hair loss;

18
Q

Hydroxychloroquine (Planquenil)

A

MOA: Antimalarial

Ind: Malaria treatment and prophylaxis; Rheumatoid arthritis; Discoid and systemic lupus

ADRs: N/D/ skin and hair changes, rash; major rare: vision changes; Bull’s eye maculopathy (need eye exams);

CI: Retinal or visual field changes; Long-term use in kids

19
Q

Sulfasalazine (Azulfidine)

A

MOA: Sulfa + salicylate; Anti-inflammatory and immunomod properties

Ind: Ulcerative colitis

Uses: Treats pain, swelling and stiffness in RA
Juvenile RA, ankylosing spondilitis, psoriatic arthritis

ADRs:
Nausea, abd discomfort
(Take w/ food and full glass of water);
photosensitivity (skin)

20
Q

Minocycline (Minocin)

A

MOA: Tetracycline antibiotic
Anti-inflammatory properties; decreases prostaglandin, metalloproteinases and leukotrienes; Increases IL-10 (ant-inflammatory)

Use: mild RA

ADRs: GI, dizziness, rash, photosensitivity

S-L-O-O-O-O-W onset
2-3 months to start working, one year for maximum benefits
ADRs: GI, dizziness, rash, photosensitivity

21
Q

Biologics

Will accept brand names!

A 
Anti-TNF:
Adalimumab (Humira)
Etanercept (Enbrel)
Infliximab (Remicade)
Certolizumab pegol (Cimzia)
Golimumab (Simponi)
Non-TNF
Abatacept (Orencia)
Rituximab (Rituxan)
Tocilizumab (Actemra)
Ustekinumab (Stelara)
Psoriasis
Psoriatic arthritis
22
Q

Anti-TNF drugs

A

MOA: Genetically engineered proteins;
Block proinflammatory cytokines: TNF-a, IL-1, IL-6

Use: when DMARDs fail
Ind: RA, psoriatic arthritis, juvenile arthritis, Crohn’s colitis, ankylosing spondylitis and psoriasis
(can be in combo w/ DMARDs)

ADRs: Infection:
URI, sinusitis, and pharyngitis; Injection-site reactions: local rash, itching, burning; infusion-related reactions, headache, and abdominal pain
30% pts D/C due to not working or bad ADRs

Caution: increased risk of infxn and reactivate latent TB (need a TB test 1st); increase HF; worsen MS; increase risk of lymphoproliferative cancer

Infliximab dosed via IV infusion; Infliximab and golimumab given with MTX;
Golimumab has longest half-life

23
Q

Non-TNF Drug Names

A

Abatacept (Orencia)
Rituximab (Rituxan)
Tocilizumab (Actemra)
Ustekinumab (Stelara)

24
Q

Abatacept (Orencia)

A

MOA: selective T-cell costimulation modulator; binds antigenic CD80/86 receptors, blocks interaction with T cell CD28; prevents stim w/ second signal (caps it off)

Ind: 2nd-line RA; juvenile arthritis after MTX and biologics (Tx swelling, pain, and prolonged joint stiffness)

CI: concomitant use with biologics (worsens infxns)

ADRs: COPD flares; HA; URI; naopharyngitis; N

25
Q

Rituximab (Rituxan)

A

MOA: chemo drug; CD20-directed cytolytic antibody; targets abn B cells, decreasing AI response

Ind: NHL, CLL; 2nd line RA; Wegener’s Granulomatosis; Micro Polyangitis

ADRs: Infusion Rxns (premed w/ prednisone, benadryl); hypotension

Warnings: Tumor lysis syndrome; SJS; TEN; Hep B reactivation; cardiac arrhythmias; renal texicity; bowl obs/perf

26
Q

Tocilizumab (Actemra)

A

MOA: IL-6 receptor antagonists; mediates T cell activation, immunoglob secretion, hematopoietic cell proliferation and diff.

Ind: RA; juvenile arthritis

ADRs: inc cholesterol; URI, nasopharyngitis, HA, HTN, inc ALT

Warnings: serious infxn, GI perf, neutropenia, live vaccines

27
Q

Ustekinumab (Stelara)

A

MOA: selectively targets IL-12 and IL-23

Ind: Psoriasis, psoriatic arthritis

ADRs: nasopharyngitis, URI, HA, fatigue, arthralgia, N

Caution: malignancies

28
Q

Guidelines

A

Look at slide 66

Low: MTX or DMARD monotherapy
Mod-High Active: DMARD monotherapy

Exam 2-MSK (3 decks)

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