clinical pharmacology of rheumatology Flashcards
drugs used in inflammatory arthritis can be classified as either
symptoms relieving drugs or disease modifiers
symptoms relieving drugs used
- paracetamol
- NSAIDS
- opiate compounds
- atypical analgesics
disease modifiers can be divided into
DMARDS and biologics
DMARDS used
methotrexate, sulfasalazine, azathioprine
biologics used
anti-TNF, rituximab, ustekinumab, secukinimab
paracetamol
- 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
NSAIDS
- have both analgesic and anti-inflammatory affect
- good for short term use but not long term due to their side effects
adverse effects of NSAIDS
- dyspepsia
- oesophagitis and gastritis
- peptic ulceration
- small intestine ulceration
- renal impairment
- fluid retention
- wheeze in aspirin sensitivity asthma
methotrexate
- can be given orally or subcutaneously
- methotrexate is a folate antagonist so everyone being prescribed it must be given folic acid supplements
adverse effects of methotrexate
- leucopenia and thrombocytopenia
- pneumonitis
- drug induced hepatitis/ cirrhosis
- rash/ mouth ulcers
- nausea and diarrhoea
- needs regular FBC and LFT monitoring
whats the issue with methotrexate especially in females
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
sulfasalizine adverse affects
- cause
- stephen johnson syndrome
- neutropenia
- hepatitis
- reversible reduction in male sperm count called oligozoosermia
- colours body fluids yellow
whats a plus of sulfasalazine
its completely safe to use in pregnancy
hydroxychloquine
pretty well tolerated but it does exacerbate psoriasis and a rare complication is retinopathy which is irreversible
anti-tnf biologic examples
infliximab, adalimumab, etanercept
What are anti-TNF drugs licensed for use in
rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis
whats the criteria for prescribing a biological agent in rheumatoid arthritis
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
adverse affects of anti-TNF treatment
- reactivation of latent tuberculosis
- contra-indicated in people with pulmonary fibrosis and heart failure
- thought to increase risk of skin cancer
other biological agents
- rituximab used in SLE, polymyositis and dermatomyositis)
- ustekinimab and secukinimab used exclusively in psoriatic arthritis that fails to respond to anti-TNF treatment
rituximab targets
B cells
ustekinumab targets
IL-12 and IL-23
Secukinimab targets
IL-17
allopurinol
never ever give in acute attacks of gout as the rapid reduction in uric acid levels can exacerbate gout
adverse effects of allopurinol
- 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
corticosteroids
have many adverse affects so should be used at the lowest possible dose for the shortest time possible
adverse effects of corticosteroids
- weight gain
- muscle wasting
- skin atrophy
- osteoporosis
- diabetes
- hypertension
- cataracts
- glaucoma
- adrenal suppression (bushings syndrome)
- immunosuppression
- avascular necrosis of the femoral head
what is used to protect bone when using steroids
vitamin D therapy and biphosphonates
