clinical pharmacology of rheumatology

Question 1

drugs used in inflammatory arthritis can be classified as either

Answer 1

symptoms relieving drugs or disease modifiers

Question 2

symptoms relieving drugs used

Answer 2

• paracetamol
• NSAIDS
• opiate compounds
• atypical analgesics

Question 3

disease modifiers can be divided into

Answer 3

DMARDS and biologics

Question 4

DMARDS used

Answer 4

methotrexate, sulfasalazine, azathioprine

Question 5

biologics used

Answer 5

anti-TNF, rituximab, ustekinumab, secukinimab

Question 6

paracetamol

Answer 6

• purely analgesic with little anti-inflammatory action
• very well tolerated at therapeutic doses and safe in pregnancy
• but very dangerous in overdose, the antidote is acetylcysteine

Question 7

NSAIDS

Answer 7

• have both analgesic and anti-inflammatory affect

- good for short term use but not long term due to their side effects

Question 8

adverse effects of NSAIDS

Answer 8

• dyspepsia
• oesophagitis and gastritis
• peptic ulceration
• small intestine ulceration
• renal impairment
• fluid retention
• wheeze in aspirin sensitivity asthma

Question 9

methotrexate

Answer 9

• can be given orally or subcutaneously

- methotrexate is a folate antagonist so everyone being prescribed it must be given folic acid supplements

Question 10

adverse effects of methotrexate

Answer 10

• leucopenia and thrombocytopenia
• pneumonitis
• drug induced hepatitis/ cirrhosis
• rash/ mouth ulcers
• nausea and diarrhoea
• needs regular FBC and LFT monitoring

Question 11

whats the issue with methotrexate especially in females

Answer 11

its teratogenic so if a female wants to become pregnant they must be taking off it 3 months prior to conception and they must never become pregnant until this point so require 2 forms of contraception

Question 12

sulfasalizine adverse affects

Answer 12

• cause
• stephen johnson syndrome
• neutropenia
• hepatitis
• reversible reduction in male sperm count called oligozoosermia
• colours body fluids yellow

Question 13

whats a plus of sulfasalazine

Answer 13

its completely safe to use in pregnancy

Question 14

hydroxychloquine

Answer 14

pretty well tolerated but it does exacerbate psoriasis and a rare complication is retinopathy which is irreversible

Question 15

anti-tnf biologic examples

Answer 15

infliximab, adalimumab, etanercept

Question 16

What are anti-TNF drugs licensed for use in

Answer 16

rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis

Question 17

whats the criteria for prescribing a biological agent in rheumatoid arthritis

Answer 17

patient must have tried at least 2 DMARDS (one being methotrexate) for at least 6 months and the DAS28 scoring system must be greater than 5.1 on 2 occasions 4 weeks apart

Question 18

adverse affects of anti-TNF treatment

Answer 18

• reactivation of latent tuberculosis
• contra-indicated in people with pulmonary fibrosis and heart failure
• thought to increase risk of skin cancer

Question 19

other biological agents

Answer 19

• rituximab used in SLE, polymyositis and dermatomyositis)

- ustekinimab and secukinimab used exclusively in psoriatic arthritis that fails to respond to anti-TNF treatment

Question 20

rituximab targets

Answer 20

B cells

Question 21

ustekinumab targets

Answer 21

IL-12 and IL-23

Question 22

Secukinimab targets

Answer 22

IL-17

Question 23

allopurinol

Answer 23

never ever give in acute attacks of gout as the rapid reduction in uric acid levels can exacerbate gout

Question 24

adverse effects of allopurinol

Answer 24

• drug induced vasculitis mainly in the elderly and those with renal impairment (so use at a lower dose)
• NEVER EVER GIVE ALLOPURINOL TO SOMEONE ON AZATHIOPRINE IT CUASES AN IRREVERSIBLE BONE MARROW SUPPRESSION

Question 25

corticosteroids

Answer 25

have many adverse affects so should be used at the lowest possible dose for the shortest time possible

Question 26

adverse effects of corticosteroids

Answer 26

• weight gain
• muscle wasting
• skin atrophy
• osteoporosis
• diabetes
• hypertension
• cataracts
• glaucoma
• adrenal suppression (bushings syndrome)
• immunosuppression
• avascular necrosis of the femoral head

Question 27

what is used to protect bone when using steroids

Answer 27

vitamin D therapy and biphosphonates