Arthritis / Gout / Osteoporosis Flashcards by Brianna Spahn

List of drugs to treat gout

Colchicine

Allopurinol (XOI)
Febuxostat (XOI)

Probenecid

Rasburicase
Pegloticase

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ACP guidelines for treating acute gout

1st - Colchicine (low dose), NSAIDs, corticosteroids

within 24 hours of onset

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ACP guidelines for initiating long term urate lowering therapy

Recommends AGAINST initiating long term therapy after FIRT gout attack or in patients with infrequent attacks

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Colchicine MOA

Not well knows

Initiates microtubule formation in bone cells
Prevents neutrophil activation

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Off label use of Colchicine

Recurrent pericarditis

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Colchicine warnings

Blood dyscrasias

Neuromuscular toxicity / RHABDO

3A4 substrate - can’t use w strong 3A4 inhibits
(Clarithromycin, Azoles, HIV drugs like Ritonavir)

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Which patient populations are at increased risk of developing neuromuscular toxicity and/or rhabdomyelosis with Colchicine?

Elderly

Renal impairment

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Which drugs are contraindicated with Colchicine

CYP 3A4 inhibitors:

Clarithromycin

Azoles (ketoconazole, itraconazole)

HIV drugs (Ritonavir, Saquinavir)

Nefazodone (antidepressant)

GRAPEFRUIT JUICE

PGP INHIBITORS

Cyclosporine
Ranolazine

*Results in INCREASED COLCHICINE PLASMA LEVELS

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Colchicine common ADRs

DIARRHEA!!!

Throat Pain

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Max dose Colchicine/day

1.2mg/day

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Xanthine Oxidase Inhibitors

CHRONIC GOUT - REDUCES PRODUCTION OF URIC ACID

Allopurinol
Febuxostat

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What’s a major drug that allopurinol interacts with?

WARFARIN

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Good reasons to use Allopurinol

Prevents progression of chronic, uncontrolled gout - decreases risk of renal damage

REDUCE TOPHI

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Patients who shouldn’t use Allopurinol

aside from acute / one time / infrequent gout pts,

Patients with recurrent calcium oxalate stones&raquo_space; Hyperuricemia

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What’s the deal with chemo patients and Allopurinol?

Chemo patients at risk of tumor lysis syndrome / hematologic malignancies

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Allopurinol ADRs

Nausea
Diarrhea
Rash

Increased LFTs

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Max dose allopurinol

800mg/day

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Downside to Febuxostat vs Allopurinol?

Higher rate of CV events

Hepatic failure reported

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Upside to Febuxostat vs Allopurinol?

No dose adjustment needed for renal impairment

Lower doses in general needed than allopurinol

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What lab is an important baseline before starting Febuxostat or Allopurinol (Xanthine Oxidase Inhibitors)?

LFT baselines!

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Which drugs work by blocking renal tubular reabsorption of urate?

Probenecid

Lesinurad (new - for refractory chronic)

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Which drug is indicated for refractory chronic gout?

Pegloticase

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What’s so special about Pegloticase

IV administration, must be given in hospital along with antihistamines and steroids to reduce anaphylaxis / infusion rxn

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Which drugs work by oxidizing uric acid into allantoin?

Pegloticase

Rasburicase

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Which drug is specifically indicated for hyperuricemia due to tumor lysis syndrome?

Rasburicase

Target serum irate levels in gout

< 5 or 6 mg/dL

High risk patients for developing allopurinol hypersensitivity rxns

HLB-5801 Han Chinese, Thai, or Koreans w CKD

3 groups of systemic corticosteroids + general MOA

Prednisone Prednisolone Methylprednisolone Inhibits cytokine production / inflammatory cell activation

Disease Modifying Drugs for Rheum Arthritis

Methrotrexate Leflunomide Hydroxychloroquine Sulfasalazine Minocycline

First line for RA

Methotrexate, low weekly dose (7.5-25mg)

Methotrexate metab location and elimination location?

Hepatic metabolism Renal elimination

Contraindications for Methotrexate

Pregnancy, or males trying to get pregnant Liver disease / alcoholism Blood dyscrasias

How long to wait after first dose before men can have unprotected sex

3 months | women = 1 cycle

Methotrexate ADRs

``` N/V/D Hair loss Rash Mouth sores Fatigue ``` Abnormal LFTs Low blood counts

Patients taking Methotrexate are at increased risk for

Infection (low blood counts)

Which RA drug works as a pyrimidine synthase inhibitor

Leflunomide (Arava)

Leflunomide (Arava) Warnings

CI in Pregnancy Hepatotoxicity

What must be monitored for patients taking Leflunomide

LFTs Baseline Then monthly for 6 months Then every 6-8 weeks

Antimalarial used for RA

Hydroxychloroquine

Contraindications for using Hydroxychloroquine

Retinal or Visual field changes Long term use in kids

Which RA drug can cause bull's eye maculopathy

Hydroxychloroquine

Which patients taking Hydroxychloroquine are more at risk of developing retinal problems

Obese elderly Renal insufficiency Long term treatment

ADR os sulfasalazine to look out for

Photosensitivity Abdominal discomfort (take w full glass water)

Anti TNF biologics for RA

Adalimumab (Humira) Infliximab Certolizumab Golimumab Etanercept

Non TNF biologics for RA

Abatacept Rituximab Tocilizumab Ustekinumab

Recommended Vitamin D dose

1,000-2,000 IU for most patients

List of Bisphosphonates - DRONATES

DRONATES! Alen-risez -iba-mornin Alendronate (Fosamax) Risedronate Ibandronate (Boniva) Zoledronic Acis

First-time user problem to look out for in Bisphosphonates DRONATES

UVEITIS / SCLERITIS

Which bisphosphonate has more GI side effects than others?

Alendronate (Fosamax)

Bisphosphonates and JAW PROBLEMS

IV Bisphosphonates especially Usually after dental extraction

What's so special about Ibandronate (Boniva)

Can be given IV, every 3 months If taken PO, must wait 60 minutes before eating or drinking

Can patients take Boniva (Ibandronate) with food?

NO - must wait 60 minutes before eating or drinking

What's so special about Zolendronate?

YEARLY 5mg IV

What can happen after first IV infusion of Zolendronate?

Flu-like symptoms

Which bisphosphonate is indicated for malignancy-associated hypercalcemia / multiple myeloma

Zoledronic Acid (Zometa - metastasise!) *monitor renal function*

Which bisphosphonate has highest incidence of ONJ?

Zoledronic Acid (Zometa) *monitor renal function*

Example of a SERM that can be used as hormonal therapy for osteoporosis in postmenopausal women

Raloxifene

Black box for Raloxifene

DVT risk, stroke risk

Black box for Teriperatide / Abaloparatide

Osteosarcoma

Which osteoporosis drug is a monoclonal antibody that inhibits osteoclast activity

DENOSUMAB

Calcitonin

Women > 5 years post menopause who can not take estrogen

Before starting anti-TNF (if a patient hasn't responded to DMARDs) what must a patient be screened for

TB - because decreased ability to fight infection a anti TNFs

Contraindications for anti TNF

Heart Failure bc patients taking anti TNF are at increased risk of cardiac mortality

Anti TNF ADRs

Infection (URI, sinus, pharyngitis) Injection site / infusion rxns

non- TNF, second line for RA and juvenile RA ayer MTX and biologics

Abatacept

Non TNF that is a cancer drug, CD20 directed cytolytic antibody (targets B cells)

Rituximab