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Pharm 2 > Bone and Joint 2 > Flashcards

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
Q

Hydroxychloroquine (Plaquenil) MOA

A

Unclear how hydroxychloroquine works in RA, but it is suspected that it decreases the T-cell respons.

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26
Q

Hydroxychloroquine (Plaquenil) use

A

Rheumatoid arthritis
Lupus
Malaria
+/- COVID?

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27
Q

Hydroxychloroquine (Plaquenil) SE

A

QT prolongation
Ototoxicity, visual disturbances, retinopathy

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28
Q

Hydroxychloroquine (Plaquenil) contraindications

A

History of liver or renal disease or use of alcohol
Preexisting retinopathy

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29
Q

What should be monitored in pts taking Hydroxychloroquine (Plaquenil)?

A

Eye examinations should be performed frequently

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30
Q

Hydroxychloroquine (Plaquenil) is used at which line in the tx regimen?

A

Last, after others have failed

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31
Q

Gold compound examples

A

gold sodium
auranofin

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32
Q

Gold compounds MOA

A

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

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33
Q

In which form are gold compounds preferred?

A

Oral gold is less efficacious, but it is better tolerated

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34
Q

Gold compound use

A

Rheumatoid arthritis
Juvenile arthritis

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35
Q

Gold compound interaction

A

None

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36
Q

Gold compound SE

A

Allergic skin rash
Nausea, vomiting, GI discomfort, altered taste (very common)

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37
Q

Gold toxicity can cause

A

decreased hemoglobin (Hb), leukopenia, reduced granulocytes, proteinuria, throat ulcers, and other reactions must be monitored

38
Q

Gold compound contraindications

A

Any history of blood dyscrasias
Dermatitis
Colitis

39
Q

Gold compound use is mostly used as a?

A

2nd line drug

40
Q

Gold compound SE warning signs

A

Pruritus is a warning sign for cutaneous reactions.
Metallic taste is a warning sign for stomatitis.

41
Q

Biologic DMARD - TNF inhibitors

A

Adalimumab (Humira) - SC
Enteracept (Enbrel) - SC
Infliximab (Remicaide) - IV

42
Q

TNF inhibitor MOA

A

Inhibit Tumor necrosis factor (TNF)-α is a potent pro-inflammatory

43
Q

TNF inhibitor use

A

Moderate to severe RA
Crohn’s disease
Plaque psoriasis
Ulcerative colitis
Hidradenitis suppurativa

44
Q

TNF inhibitors can be used concurrently with?

A

MTX

45
Q

TNF inhibitor SE

A

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
Q

TNF inhibitor interactions

A

NONE

47
Q

TNF inhibitor contraindications

A

Patients with serious infections: Tuberculosis or sepsis

48
Q

TNF inhibitors black box warning

A

Increased risk of serious infection

49
Q

Pts on TNF inhibitors should be screened for what?

A

Patients must be screened for latent or active tuberculosis as a precautionary measure.

50
Q

Long term use of TNF inhibitors can cause what?

A

It is believed its long-term suppression may increase infections or malignancies

51
Q

Interleuikin 6 inhibitor examples

A

Tocilizumab (Actemra) – IV infusion
Sarilumab (Kebzara) – SubQ

52
Q

Interleuikin 6 Inhibitors MOA

A

Endogenous IL-6 is induced by inflammatory stimuli and mediates a variety of immunological responses

53
Q

Interleuikin 6 Inhibitors use

A

Rheumatoid arthritis

54
Q

Janus Kinase Inhibitors examples

A

Tofacitnib (Xaljanz) – PO

55
Q

Janus Kinase Inhibitors MOA

A

Inhibit JAK - intracellular enzymes involved in stimulating hematopoiesis and immune cell function through a signaling pathway

56
Q

JAK inhibitor use

A

Rheumatoid arthritis
Psoriatic arthritis
Ulcerative colitis

57
Q

What causes gout?

A

urate crystals within the tissues due to high levels of circulating uric acid in the blood

58
Q

Where do gout attacks occur?

A

base of the first toe

59
Q

Acute gout management should focus on?

A

focus on managing inflammation, eases the inflammatory response without spreading the urate crystals

60
Q

Which drugs should be avoided during gout flares?

A

Avoid aspirin and other salicylates that may enhance uric acid reabsorption by the kidney at low doses

61
Q

Which drugs are used to tx acute gout?

A

colchicine, probenecid, allopurinol, Sulfinpyrazone, corticosteroids, and NSAIDs (pain relief)

62
Q

Which NSAIDs are preferred for acute gout?

A

Naproxen or indomethacin are preferred

63
Q

What is the most important food/ drink to avoid in gout?

A

Limit alcohol intake because it increases serum levels of urates

64
Q

Allopurinol (Zyloprim) MOA

A

Inhibits the enzyme xanthine oxidase, blocking the production of uric acid

65
Q

Allopurinol (Zyloprim) use

A

Chronic gouty arthritis
Prevention of uric acid calculi

66
Q

Allopurinol (Zyloprim) SE

A

Rash following injection; if the rash is severe, consider it toxic; urticaria
Renal failure
Bone marrow depression
Sensitivity reactions possible after prolonged use

67
Q

Allopurinol (Zyloprim) contraindications

A

Nursing mothers and children
History of hypersensitivity reactions

68
Q

Allupurinol combined with which med can increase risk of SJS?

A

ACE inhibitors

69
Q

Allupurionol and probenecid do what when combined?

A

Increases the half-life of probenecid and enhances its uricosuric effect BUT allupurinol dose needs to be doubled

70
Q

During the first few wks of Allopurinol (Zyloprim) use, what can happen?

A

May see increased attacks of gout during initial treatments

71
Q

Colchicine (generic) MOA

A

Interferes with migration of neutrophils to sites of inflammation

72
Q

Colchicine use

A

acute gout attacks - relief in 12 hrs

73
Q

Allupurinol can do what to the anticoagulant effect?

A

allopurinol increases the anticoagulant effect

74
Q

Colchicine SE

A

diarrhea*
Agranulocytosis, aplastic anemia, leukopenia, thrombocytopenia

75
Q

Colchicine combined with NSAIDs can do what?

A

Have an additive GI effect

76
Q

Colchicine should be avoided in pts w/ a hx of?

A

renal impairment

77
Q

Max dosing of Colchicine - to avoid OD

A

Maximum recommended dose for treatment of gout flares is 1.8 mg over a 1 hour period

78
Q

If a pt is taking prophylactic colchicine and experiences an attack, what should they do?

A

Patients taking prophylactic colchicine should not increase doses if a gouty attack occurs.

79
Q

Probenecid (Probalan) MOA

A

Inhibits renal tubular reabsorption of uric acid, thus promoting its renal secretion

80
Q

Probenecid (Probalan) use

A

Chronic gout
Patients with gonorrhea or neurosyphilis (by delaying the excretion of penicillin)

81
Q

Probenecid (Probalan) SE

A

sore gums, drug-induced hepatitis

82
Q

Probenecid should be avoided in pts w/ a hx of?

A

Renal fx

83
Q

Probenecid (Probalan) should be taken at the same time every day because?

A

Erratic dosing schedules may cause raised levels of uric acid and precipitate an attack of gout.

84
Q

Febuxostat (Uloric) MOA

A

Xanthine oxidase inhibitor which acts by decreasing serum uric acid

85
Q

What 2 steps (in addition to diet changes and meds) can be done to avoid uric acid crystal formation?

A
  • 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
Q

Febuxostat (Uloric) use

A

Gout

87
Q

Febuxostat (Uloric) SE

A

Myocardial infarction, Death
SJS
Increased liver enzymes
Cerebrovascular accident

88
Q

Febuxostat (Uloric) black box warning

A

Higher risk of cardiovascular death (avoid in pts w/ hx of CAD)

89
Q

Which drugs should be avoided when taking Febuxostat (Uloric)?

A

Concomitant administration of drugs that are metabolized by xanthine oxidase (e.g., theophylline, mercaptopurine, azathioprine)

90
Q

When tx a pt with gout and hx of cardiovascular disease, which drug should be avoided?

A

Febuxostat (Uloric)

91
Q

Which things should be monitored for in pts taking Febuxostat (Uloric)?

A

liver toxicity, serum uric acid levels

Pharm 2 (8 decks)

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