Arthritis Medications Flashcards
↓ pain ↓ damage ↑/maintain function ↑/maintain QOL ↑/maintain work productivity
OA Patient Priorities
↓ pain ↓ damage ↑/maintain function ↑/maintain QOL ↑/maintain work productivity
Stop joint swelling, stiffness, fatigue, damage ( = remission)
Inflammatory Arthritis Patient Priorities
↓ pain ↓ damage ↑/maintain function ↑/maintain QOL ↑/maintain work productivity
Prevent comorbidities
Prevent complications
Delay need for surgery
OA Physician Priorities
↓ pain ↓ damage ↑/maintain function ↑/maintain QOL ↑/maintain work productivity
Prevent comorbidities
Prevent complications
Delay need for surgery
*Induce remission where possible
Inflammatory Arthritis Physician Priorities
Good disease control = better participation in PT, ↑ physical activity, ADLs, work productivity, life roles
Poor medication adherence = major cause of disease progression + disability, morbidity, health care cost
Only 1 in 5 RA pt’s take medications as prescribed at > 80% adherence
Often stigma & fear around medication
Educate pt’s: Importance of pain & disease control for their QoL & function, redirect to pharmacist/MD for more detailed information or followup
Reassurance and education
PT Role in Medication Adherence
1) Patient related factors
- socio-demographics, psycho-social profile, comorbidities, cognitive ability, health literacy, & *health beliefs)
2) Drug-related factors
- # of drugs taken, adverse effects, & administration regimes -> med review by pharmacy
3) Other factors
- patient-prescriber relationship, access to medications, social support
3 Categories of Barriers to Medication Adherence
Analgesia
Disease Modifiers
Arthritis Medication Categories
Control pain (& some inflammation)
- Acetaminophen/paracetamol
- NSAIDs
- Steroids (short-course)
- Drugs for off-label use (central/neuropathic pain)
- Opioids
Analgesia
Control disease by modifying or suppressing immune inflammatory response
- NSAIDs (only in spondylitis)
- Corticosteroids
- Disease Modifying Anti-rheumatic Drugs (DMARDs)
- Biologic Disease Modifying Anti-rhuematic Drugs (Biologic DMARDs or “Biologics”)
Used for control of abnormal inflammatory pathways in INFLAMMATORY arthritis
- 1st Line Tx: DMARDs
- 2nd line Tx: Biologic DMARDs
- Adjuncts: Corticosteroids; analgesics, NSAIDs
*Exception: NSAIDs can be used as 1st line tx. in Axial Spondylitis
Disease Modifiers
Analgesic
Ex: Tylenol
Function: ↓ pain (also fever reducing)
Use: 1st line of OA; control of mild to moderate joint pain; 1-2 hours to take effect
Precautions for PT:
- None; generally fewer side effects & tolerated better than NSAIDs & safer in elderly w/ comorbidities
- Safe to take in combination w/ NSAIDs or other arthritis meds
- Hepatotoxic past 4g (4,000mg)/day or w/ alcohol can result in liver failure
Acetominophen
Analgesic
Ex:
- OTC oral tablet = Aspirin, ibuprofen, naproxen
- Topical cream/gel
- Prescription NSAIDs
Function: ↓ pain, swelling, stiffness & fever
Use:
- Primarily in OA; spondylitis for joint pain & inflammation
- *High intake slows new bone formation in individuals w/ ↑ C-reactive protein (CRP) only
- Analgesia 30-60mins, steady state after 2 days (few days to 1 week for optimal anti-inflammatory effects)
Precautions for PT:
- Raises BP
- ↑ CV event risk (non-aspirin), but the risk is lower than smoking/hypertension
- Make sure to not combine 2 types together
- Topical’s have similar effects & safer
NSAIDs
Analgesic
Name: Serotonin-Norepinephrine Reuptake Inhibitor (SNRI): e.g. Duloxetine (prescription oral capsule)
Function: Second-line analgesic agent where no/partial response to acetaminophen/NSAIDs; takes effect within 1 week
Use: Neuropathic pain in OA (also fibromyalgia, anxiety, depression)
Precautions for PT:
- Side effects: dizziness/light-headedness
- May raise BP
Other Analgesics
Ex: Codeine, Hydromorphone, Oxycodone, Fentanyl, Morphine
Function: ↓ pain
Use:
- Second-line Rx for mod-to-severe OA pain; not commonly used as often risk>benefit
- No data on benefit for inflammatory arthritis past 6 weeks
- Works within 1 hr
Precautions for PT:
- Side effects: drowsiness, dizziness, constipation
- Opioid tolerance with prolonged use can sensitize to pain
- Risk of dependence w/ chronic use
Opioids
Prescribed for:
- Acute/chronic pain resulting from disease, surgery, or injury
- Moderate to severe coughs & diarrhea
- Treat addiction to other opioids such as heroin or oxycodone (e.g. methadone, suboxone)
- Controlling pain in terminal illness
Can produce both analgesia & euphoria = potential for abuse
Easy to become addicted
Long term use can lead to:
- ↑ tolerance to the drug, so that more is needed to produce same pain relieving effect
- Dependence
- Withdrawal symptoms
Recommended optimization of non-opioid pharmacotherapy & non-pharmacologic therapy rather than a trial of opioids for pt’s with chronic non-cancer pain (in which most have back pain or OA)
Opioids
Disease Modifier
Ex: Methotrexate (MTX) - oral tablets or subcutaneous injection
Function: Prevent joint damage by suppressing inflammatory pathways; can take up to 3 MONTHS for full effect
Use: IA = RA, JIA, Psoriatic arthritis, Lupus
Precautions for PT:
- Side effects: nausea & fatigue the day after (taking folic acid/folinic acid - aka leukovorin improves this)
DMARDs
Disease Modifier
Large, complex proteins made from living cells through highly complex manufacturing processes
- Tend to be more VARIABLE & structurally COMPLEX than chemically synthesized drugs
Ex: Etanercept, Adalimumab, Infliximab (subcutaneous injection or IV infusion)
Function: Prevent joint damage by suppressing inflammatory pathways; reserved for people who have NOT responded adequately to conventional DMARDs & for those who cannot tolerate DMARDs in doses large enough to control inflammation
Use: RA, Axial Spondylitis, etc.
Precautions for PT:
- ↑ risk of serious infections (e.g. pneumonia, cellulitis)
- Sterile technique if dry needling, keep environment hygienic (clean plinths, pillow covers)
Biologics
Biologic drugs are large, complex proteins made from living cells through highly complex manufacturing processes
A Biosimilar is a copy of biologic medicine that is similar, but not identical to the original medicine
To be called a biosimilar, these compounds need to demonstrate structural & functional similarities with comparable pharmacokinetic and pharmacodynamic properties to the references product
Biologics vs Biosimilars
Drugs that enter the market subsequent to a previously authorized version (i.e. biologics) whose patent has expired
Approved only after showing that it is “highly similar” to an approved biological product (reference product), in therms of:
- Safety
- Purity
- Potency
- Efficacy w/ allowable minor differences
Biosimilars
Present & clarify benefits & harms of tx options based on available research
Help pt’s communicate questions, concerns, & preferred choice to rheumatologists
Promote SHARED DECISION-MAKING
- The process by which a healthcare choice is made jointly by the health professional & the pt
Ex:
- Methotrexate Patient Decision Aid
- Biologic Patient Decision Aid
Patient Decision Aids
Disease Modifier
Ex:
- Prescription oral tablet = Prednisone
- Injection = methylprednisolone, triamcinolone
Function:
- Most efficacious anti-inflammatory drug available
- Oral takes effect within 1-4 days
- Injections 24-48h (rest joint)
Use: OA (joint injection), Inflammatory Arthritis (oral or injection)
Precautions for PT: (with >2months oral use)
- ↓ bone density & risk of # w/ long term use
- ↑ blood sugars
- ↑ muscle wasting
- ↑ infection risk
- Small risk of avascular necrosis
- Do NOT combine w/ alcohol or large amounts of NSAIDs
- Risk of GI ulceration
Corticosteroids
Corticosteroids in vitro can ↓ cell proliferation & collagen synthesis, collagen disorganization, & necrosis
Underlying tendinopathy, mechanical failure, & cartilage erosion often already present in inflammatory arthritis & OA
If joint/tendon inflammation is NOT controlled, risk of joint damage/tendon rupture -> risk of corticosteroid injection in IA
Corticosteroid Cartilage & Tendon Effects
Corticosteroid injections provide powerful, localized anti-inflammatory effects so patient can resume function/participate in rehab
Some situations very beneficial to have anti-proliferative effects (e.g. trigger finger, tenosynovitis)
Often standard interventions adjunctive with or following failure of conservative tx. prior to surgical intervention
No longer inject directly into tendons
Injection Controversy
1st line: NSAIDs
2nd line: Anti-TNF inhibitors (Biologics) for people who do not respond to NSAIDs
Conditionally recommend continuous tx. w/ NSAIDs over on-demand tx.
Axial Spondylitis Tx
- Acetaminophen & other
- NSAIDs
- Corticosteroid intra-articular injections
OA Meds
- Can use Acetaminophen & other NSAIDs
- Can use NSAIDs
- Corticosteroids (oral)
- Conventional DMARDs
- Biologic/Biosimilar DMARDs
- Corticosteroid intra-articular injections
RA Meds
- NSAIDs
- Biologic/Biosimilar DMARDs
- Corticosteroid intra-articular injections
AxSpA Meds
