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Bone and Joint 2 Flashcards

1
Q

How do DMARDs work on RA?

A

Influence the disease process of RA by preventing bone loss and cartilage erosion - better outcome the earlier they are introduced

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2
Q

How are DMARDs prescribed to tx in a regimen?

A

They are prescribed in combination with biological DMARDs or in multiple drug regimens, including NSAIDs, other DMARDs, and sometimes corticosteroids

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3
Q

How long should NSAIDs be trialed before a DMARD is added to the regimen?

A

NSAIDs as monotherapy should be given a trial of no longer than 3 months

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4
Q

If adequate response is achieved with a DMARD, what role do NSAIDs play in the regimen?

A

an NSAID can be used as needed in many patients

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5
Q

In which situations are steroids used to tx RA?

A
  • Early in treatment to provide symptomatic relief while waiting for a DMARD to work
  • In low doses chronically for patients who fail to get an adequate response from a DMARD
  • In bursts to treat acute flare-ups of disease
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6
Q

DMARD examples

A

Methotrexate (Folex, Rheumatrex)
Leflunomide (Arava)
Hydroxychloroquine (Plaquenil)

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7
Q

Methotrexate (Rheumatrex) MOA

A

Folate antimetabolite that inhibits DNA synthesis, repair, and cellular replication - cell antiproliferative

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8
Q

MTX uses

A

Psoriasis
Systemic lupus erythematosus
Sarcoidosis
Antifolate chemotherapeutic drug in treatment of lung, head and neck, and breast cancers and leukemia
Rheumatoid arthritis

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9
Q

MTX SE

A

Alopecia, photosensitivity, pruritus
Nausea, mucosal ulceration, vomiting
Infertility
Anemia, thrombocytopenia
Increased liver enzymes
Nephrotoxicity
Osteonecrosis, stress fractures

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10
Q

When combined with these drugs, the risk of hematological toxicity while on MTX increases. What are the drugs?

A

Increases when given with high doses of salicylates, NSAIDs, oral hypoglycemics, tetracyclines, or sulfonamides

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11
Q

What diseases can MTX induce?

A

Liver or kidney disease may be induced

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12
Q

What drink can lower the effect of MTX?

A

Caffeine will lower the effect of methotrexate

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13
Q

Which herbals can interact with MTX and why?

A

Concomitant use with herbals such as echinacea and melatonin interfere with immunosuppression

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14
Q

MTX contraindications

A

Pregnancy - teratogenic (wait 1 menses or 3 months for men)
Chronic liver disease
Preexisting blood dyscarasis

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15
Q

What is the most effective DMARD?

A

MTX

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16
Q

What supplement should be prescribed along side of MTX?

A

In all patients taking chronic low-dose methotrexate, it is recommended to prescribe folic acid or leucovorin (folinic acid)

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17
Q

MTX can cause immunosuppression, what should be avoided while on the drug?

A
  • Avoid crowds and persons with any infections
  • Use a soft toothbrush and an electric shaving razor
  • Avoid falls
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18
Q

Leflunomide (Arava) MOA

A

Immunomodulary - inhibits pyrimidine synthesis, resulting in antiproliferative and anti-inflammatory effects.

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19
Q

Leflunomide (Arava) use

A

slow progression of rheumatoid arthritis and joint destruction

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20
Q

Leflunomide (Arava) interactions

A

hepatotoxic drug will increase the likelihood of hepatotoxicity

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21
Q

Leflunomide (Arava) SE

A

Hypertension
Alopecia, pruritic rash
Diarrhea, nausea, abdominal pain, abnormal liver enzymes, hepatotoxicity
Back pain
Headache, dizziness, weakness
Bronchitis, rhinitis

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22
Q

Leflunomide (Arava) contraindications

A

Pregnancy and liver disease

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23
Q

Which labs should be monitored in pts on Leflunomide (Arava)?

A

elevated bilirubin and elevated alkaline phosphatase

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24
Q

Important counseling point for women taking leflunomide?

A

teratogenic effect

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25
Hydroxychloroquine (Plaquenil) MOA
Unclear how hydroxychloroquine works in RA, but it is suspected that it decreases the T-cell respons.
26
Hydroxychloroquine (Plaquenil) use
Rheumatoid arthritis Lupus Malaria +/- COVID?
27
Hydroxychloroquine (Plaquenil) SE
QT prolongation Ototoxicity, visual disturbances, retinopathy
28
Hydroxychloroquine (Plaquenil) contraindications
History of liver or renal disease or use of alcohol Preexisting retinopathy
29
What should be monitored in pts taking Hydroxychloroquine (Plaquenil)?
Eye examinations should be performed frequently
30
Hydroxychloroquine (Plaquenil) is used at which line in the tx regimen?
Last, after others have failed
31
Gold compound examples
gold sodium auranofin
32
Gold compounds MOA
Unclear - compounds interfere with interleukin-1 (IL-1), a protein that is a major mediator of joint disease, and TNF-alpha OR gold is taken up by mononuclear cells and inhibits their phagocyte function
33
In which form are gold compounds preferred?
Oral gold is less efficacious, but it is better tolerated
34
Gold compound use
Rheumatoid arthritis Juvenile arthritis
35
Gold compound interaction
None
36
Gold compound SE
Allergic skin rash Nausea, vomiting, GI discomfort, altered taste (very common)
37
Gold toxicity can cause
decreased hemoglobin (Hb), leukopenia, reduced granulocytes, proteinuria, throat ulcers, and other reactions must be monitored
38
Gold compound contraindications
Any history of blood dyscrasias Dermatitis Colitis
39
Gold compound use is mostly used as a?
2nd line drug
40
Gold compound SE warning signs
Pruritus is a warning sign for cutaneous reactions. Metallic taste is a warning sign for stomatitis.
41
Biologic DMARD - TNF inhibitors
Adalimumab (Humira) - SC Enteracept (Enbrel) - SC Infliximab (Remicaide) - IV
42
TNF inhibitor MOA
Inhibit Tumor necrosis factor (TNF)-α is a potent pro-inflammatory
43
TNF inhibitor use
Moderate to severe RA Crohn’s disease Plaque psoriasis Ulcerative colitis Hidradenitis suppurativa
44
TNF inhibitors can be used concurrently with?
MTX
45
TNF inhibitor SE
CHF (Worsening or new onset) Abdominal pain Neutropenia, Increased liver enzymes Life-threatening infections, infusion reactions, UTIs, viral infections, malignancy Headache Bronchitis, increased upper respiratory infections (URIs), rhinitis
46
TNF inhibitor interactions
NONE
47
TNF inhibitor contraindications
Patients with serious infections: Tuberculosis or sepsis
48
TNF inhibitors black box warning
Increased risk of serious infection
49
Pts on TNF inhibitors should be screened for what?
Patients must be screened for latent or active tuberculosis as a precautionary measure.
50
Long term use of TNF inhibitors can cause what?
It is believed its long-term suppression may increase infections or malignancies
51
Interleuikin 6 inhibitor examples
Tocilizumab (Actemra) – IV infusion Sarilumab (Kebzara) – SubQ
52
Interleuikin 6 Inhibitors MOA
Endogenous IL-6 is induced by inflammatory stimuli and mediates a variety of immunological responses
53
Interleuikin 6 Inhibitors use
Rheumatoid arthritis
54
Janus Kinase Inhibitors examples
Tofacitnib (Xaljanz) – PO
55
Janus Kinase Inhibitors MOA
Inhibit JAK - intracellular enzymes involved in stimulating hematopoiesis and immune cell function through a signaling pathway
56
JAK inhibitor use
Rheumatoid arthritis Psoriatic arthritis Ulcerative colitis
57
What causes gout?
urate crystals within the tissues due to high levels of circulating uric acid in the blood
58
Where do gout attacks occur?
base of the first toe
59
Acute gout management should focus on?
focus on managing inflammation, eases the inflammatory response without spreading the urate crystals
60
Which drugs should be avoided during gout flares?
Avoid aspirin and other salicylates that may enhance uric acid reabsorption by the kidney at low doses
61
Which drugs are used to tx acute gout?
colchicine, probenecid, allopurinol, Sulfinpyrazone, corticosteroids, and NSAIDs (pain relief)
62
Which NSAIDs are preferred for acute gout?
Naproxen or indomethacin are preferred
63
What is the most important food/ drink to avoid in gout?
Limit alcohol intake because it increases serum levels of urates
64
Allopurinol (Zyloprim) MOA
Inhibits the enzyme xanthine oxidase, blocking the production of uric acid
65
Allopurinol (Zyloprim) use
Chronic gouty arthritis Prevention of uric acid calculi
66
Allopurinol (Zyloprim) SE
Rash following injection; if the rash is severe, consider it toxic; urticaria Renal failure Bone marrow depression Sensitivity reactions possible after prolonged use
67
Allopurinol (Zyloprim) contraindications
Nursing mothers and children History of hypersensitivity reactions
68
Allupurinol combined with which med can increase risk of SJS?
ACE inhibitors
69
Allupurionol and probenecid do what when combined?
Increases the half-life of probenecid and enhances its uricosuric effect BUT allupurinol dose needs to be doubled
70
During the first few wks of Allopurinol (Zyloprim) use, what can happen?
May see increased attacks of gout during initial treatments
71
Colchicine (generic) MOA
Interferes with migration of neutrophils to sites of inflammation
72
Colchicine use
acute gout attacks - relief in 12 hrs
73
Allupurinol can do what to the anticoagulant effect?
allopurinol increases the anticoagulant effect
74
Colchicine SE
diarrhea* Agranulocytosis, aplastic anemia, leukopenia, thrombocytopenia
75
Colchicine combined with NSAIDs can do what?
Have an additive GI effect
76
Colchicine should be avoided in pts w/ a hx of?
renal impairment
77
Max dosing of Colchicine - to avoid OD
Maximum recommended dose for treatment of gout flares is 1.8 mg over a 1 hour period
78
If a pt is taking prophylactic colchicine and experiences an attack, what should they do?
Patients taking prophylactic colchicine should not increase doses if a gouty attack occurs.
79
Probenecid (Probalan) MOA
Inhibits renal tubular reabsorption of uric acid, thus promoting its renal secretion
80
Probenecid (Probalan) use
Chronic gout Patients with gonorrhea or neurosyphilis (by delaying the excretion of penicillin)
81
Probenecid (Probalan) SE
sore gums, drug-induced hepatitis
82
Probenecid should be avoided in pts w/ a hx of?
Renal fx
83
Probenecid (Probalan) should be taken at the same time every day because?
Erratic dosing schedules may cause raised levels of uric acid and precipitate an attack of gout.
84
Febuxostat (Uloric) MOA
Xanthine oxidase inhibitor which acts by decreasing serum uric acid
85
What 2 steps (in addition to diet changes and meds) can be done to avoid uric acid crystal formation?
- Patients may be given sodium bicarbonate or potassium citrate to alkalize the urine. - Patients need to drink 2,000 to 3,000 mL of fluid per day.
86
Febuxostat (Uloric) use
Gout
87
Febuxostat (Uloric) SE
Myocardial infarction, Death SJS Increased liver enzymes Cerebrovascular accident
88
Febuxostat (Uloric) black box warning
Higher risk of cardiovascular death (avoid in pts w/ hx of CAD)
89
Which drugs should be avoided when taking Febuxostat (Uloric)?
Concomitant administration of drugs that are metabolized by xanthine oxidase (e.g., theophylline, mercaptopurine, azathioprine)
90
When tx a pt with gout and hx of cardiovascular disease, which drug should be avoided?
Febuxostat (Uloric)
91
Which things should be monitored for in pts taking Febuxostat (Uloric)?
liver toxicity, serum uric acid levels

Pharm 2 (8 decks)

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