Arthritis Flashcards
Outline treatment options for Osteoarthritis and non-drug measures than can be taken?
- Paracetamol (may need to be taken regularly)
- Topical NSAIDs or Capsaicin 0.025% - particularly for knee and hand
- Oral NSAIDs can sub or add on to paracetamol (topical should be stopped)
- Opioids
- Intra-articular corticosteroid injections
Weight loss and exercise
What are three treatments that are available OTC but are not recommended for osteoarthritis?
- Glucosamine
- Rubefacients
- Hyaluronic acid
Symptoms of rheumatoid arthritis?
- Pain
- Prolonged stiffness - tends to be worse at rest or following periods of inactivity
- Swelling
- Tenderness
- Rheumatoid nodules
- Non-specific symptoms such as malaise, fatigue, fever and weight loss
What is palindromic rheumatism and what makes it different to rheumatoid arthritis?
Rare form of inflammatory arthritis which causes attacks of joint pain and swelling similar to rheumatoid but the joints return to normal in between attacks.
Non-drug treatment for rheumatoid arthritis? (2)
Physiotherapy - exercise, enhance flexibility of joints and strengthen muscles
Psychological - relaxation, stress management
Drug treatment for active rheumatoid arthritis?
First line for newly diagnosed active:
monotherapy with
- Disease modifying antirheumatic drug (DMARD)
- Oral methotrexate
- Leflunomide
- Sulfasalazine
Should be started ideally 3 months of onset of persistent symptoms.
Dose titrated up to maximum tolerated effective dose.
What drug treatment can be used in those with mild rheumatoid or palindromic arthritis?
Hydroxychloroquine sulphate )( weak DMARD)
Conventional DMARDs have a slow onset of action and can take ____months to take effect.
What can be used as a bridging treatment?
2-3 months
Short term corticosteroid - oral, intramuscular or intra-articular
If symptoms aren’t adequately controlled despite dose escalation of DMARD. What are the next steps?
What is an alternative for severe active RA?
- Combination therapy with another DMARD
2. Tumor necrosis factor (TNF) alpha inhibitor or other biological DMARD or synthetic DMARD
Rituximab in combination with methotrexate is an alternative option for severe active RA.
Pain relief in RA.
Short term NSAID or selective COX2 inhibitor can be used to help with pain and stiffness.
What should patients be given to help with possible side effects?
What if the patient is on low dose aspirin?
Proton pump inhibitor should be given to reduce GI effects.
In low dose aspirin - paracetamol or compound analgesic should be considered before NSAID.
NSAIDs should be given lowest effective dose and withdrawn when good response to DMARD is achieved.
How often should patients with active RA and other RA patients be monitored?
Active RA - monthly until treatment target is achieved
All other pts - annually
How long should a standard DMARD be taken for at max tolerated dose before switching or adding another?
What other adjuncts can be considered?
3 months
NSAIDs - if not working then
Injections or short term oral Corticosteroids
Choice of DMARD depends on different factors such as:
- Pregnancy planning
- Alcohol consumption
- Comorbidities - uveitis, psoriasis and IBD
What is Gold licensed for?
In what form is it given and via which route?
Active progressive rheumatoid arthritis
given as sodium aurothiomalate via deep intramuscular injection and area is gently massaged.
Can patients be started & continued on Gold straight away?
What is the procedure?
No - a test dose (10mg) must be given first followed by weekly doses (50mg10 until a definite evidence of remission.
In pts who do respond - interval between injections increased to 4 weeks and treatment continued for up to 5 years after complete remission.
What if a relapse occurs during/after treatment with Gold?
Dosage frequency increased and when controlled can be decreased again.
If no response after 2 months = alternative treatment
Avoid complete relapse since 2nd course of gold not usually effective.
Main contra-indications and side effects for Gold/Sodium aurothiomalate?
Blood disorders
Patients should be warned not to expect improvement for at least____ weeks after treat with Penicillamine
When should treatment be discontinued if no improvement?
6 to 12 weeks
Within 1 year
In addition to RA, what else is Penicillamine indicated for? (2)
Which form is the pharmaceutical form?
- Wilson’s disease (copper builds up in body)
- Cystinuria (build up of amino acid cytokine in kidneys)
D- form
L form is toxic
What are some common side effects with Penicillamine? (4)
Proteinuria - if this occurs probably due to nephrotoxicity - if so discontinue.
Thrombocytopenia
Nausea
Rash - can occur months after starting treatment - can reduce dose.
In addition to RA what else if Sulfasalazine (aminosalicylte) used for? (2)
Ulcerative colitis
Crohn’s disease
What are some common side effects of Sulfasalazine? (8)
Side effect in particular pts should be on the look out for signs - should be discontinued & what else should occur?
- Arthralgia
- Cough
- Taste disturbance
- Diarrhoea, Vomiting, GI disturbances
- Tinnitus
- Urine abnormalities
- Leucopenia
- Skin reactions
Haematological Blood disorder - Blood count performed and drug stopped
Monitoring for Sulfasalazine? (3)
- Blood disorders - blood counts first 3 months
- Renal function - before treatment, at 3 months and then annually
(maintain fluid intake) - Liver function - monthly for first 3 months
Sulfasalazine can colour bodily fluids and contact lenses what colour?
Yellow - orange
Hydroxychloroquine sulfate and chloroquine can be used for inflammatory disorders & in lupus erythrmatosus.
But they should not be used in which specific arthritis?
Psoriatic arthritis
Hydroxychloroquine sulfate and chloroquine should be monitored for _____?
What are the monitoring recommendations?
Retinopathy (more common than previously reported)
Hard to distinguish from normal aging in elderly.
- All pts planning long term - should have baseline exam within 6-12months of treatment initiation
- Annual monitoring for those have been on it 5 years or longer
- Annual monitoring may be started before 5 years treatment if additional risk factors for retinopathy toxicity exists such as:
- Impaired renal function (egfr less than 60ml)
- High dose therapy
- Concomitant tamoxifen (breast cancer) therapy.
To avoid excessive dosage in obese patients - what should the dose be based on ?
Based on ideal body weight
Two serious signs of hydroxychloroquine toxicity /overdose?
Urgent advice from the National Poisons Information Service is essential.
1. Arrhythmias (which can have a very rapid onset)
- Convulsions (which can be intractable).
Common side effects of hydroxychloroquine? (6)
- Abdo pain, diarrhoea, vomiting, nausea
- Appetite decreased
- Emotional lability
- Headache
- Vision disorders
- Skin reactions
Uncommon side effects of hydroxychloroquine? (3)
- Alopecia, hair colour changes
- Corneal oedema, Eye disorders
- Seizure, Tinnitus, Vertigo
How often is Methotrexate given? & what should be given with it?
Weekly & max Dose for RA?
Weekly (same day) 7.5mg
Max 20mg for moderate to severe
Max 25mg for severe
Folic acid weekly on a different day
Methotrexate MOA?
Methotrexate inhibits the enzyme dihydrofolate reductase, essential for the synthesis of purines and pyrimidines.
What is methotrexate used for? (3)
- Severe Crohn’s disease
- Severe RA
- Severe Psoriasis
Contra-indications for methotrexate? (4)
- Active infection
- Ascites
- Immunodeficiency
- Significant pleural effusion
Cautions for methotrexate? (4)
What should happen if signs of one happening?
- Blood count. Bone marrow suppression can occur abruptly. If significant drop in white cell/platelet count = immediate withdrawal of methotrexate.
- GI toxicity.
Diarrhoea or stomatitis = withdraw treatment as could be first signs of toxicity - Liver toxicity. Treatment should not started or continued if abnormalities in liver function, can return to normal within 2 weeks - treatment can be started again if judged appropriate. Persistent increases in liver transaminases may nay reduction or discontinuation.
- Pulmonary toxicity. pts to seek help if dyspnoea, cough or fever develops, monitor symptoms at each visit. discontinue if pneumonitis.
Common side effects of methotrexate?
Intrathecal
Oral
Parenteral
Intrathecal:
- Necrotising demyelinating leukoencephalopathy
- Neurotoxicity
Oral:
- Anaemia, fatigue, malaise
- Cough, dyspnoea, respiratory disorders, throat complaints/ulcer, chest pain,
- Diarrhoea, vomiting, nausea
- Thrombocytopenia, leucopenia, increased risk of infection
Parenteral:
Same as Oral
Why do we give folic acid with methotrexate?
Folic acid decreases mucosal and gastrointestinal side-effects of methotrexate and may prevent hepatotoxicity
What can be used to treat methotrexate acute toxicity?
folinic acid (as calcium folinate)
Conception and contraception advice for methotrexate?
contraception during and for at least 6 months after treatment in men and women
Can methotrexate be used in
Pregnancy
Breastfeeding
Renal impairment
Hepatic impairment
Pregnancy: avoid. teratogenic, fertility may be reduced during therapy but may be reversible
Breastfeeding: discontinue- present in milk
Renal: Risk of nephrotoxicity high. Avoid in severe. Reduce dose
Hepatic:
Avoid in non-malignant conditions.
If used in malignancy avoid in severe.
Outline the pre-screening for methotrexate? (4)
- Rule out pregnancy
- Blood count
- Renal function
- Liver function
What are the monitoring requirements for methotrexate?
- Full blood count
- Renal
- Liver
repeated every 1-2 weeks until therapy stabilised. After which every 2-3 months
Advised to report all symptoms/signs of infection especially sore throat
Patient advice for methotrexate?
- Report any symptoms of toxicity, infection, respiratory effects etc
- Don’t self medicate/ OTC aspirin/ibuprofen/NSAIDs
- Weekly ORAL dose, same day. Pt alert card.
How long does it take to see effects of Leflunomide?
Also how long after treatment can you see effects?
start after 4-6 weeks and improvement may continue for a further 4-6 months.
Give examples of cytokine modulators and their MOA.
Adalimumab Certolizumab Etanercept Golimumab Infliximab
Inhibit the activity of tumour necrosis factor alpha (TNF-a)
