Drugs for Mobility Flashcards
What is gout?
Recurrent inflammatory disorder
Name 3 ways that gout can occur
- Increased uric acid production
- Under excretion of UA
- Increased intake of foods containing purines
WTF is heckin’ purine?
Chemical compound in food known to cause gout. Forms UA when metabolized.
Who is most at risk for gout?
Males, ETOH, folks on diuretics, people who are immunosuppressed.
True or false: Stress cannot induce a gout attack.
FALSE. It sure can.
Three main anti-inflammatory agents used in an acute gout attack:
NSAIDS
Glucocorticoids
Colchicine
3 main NSAIDS used to treat an acute gout attack:
Indomethacin
Naproxen
Diclofenac Sodium
If the patient has less than 3 gout attacks a year, how will we treat when s/s arise?
Symptomatically (versus preventative)
What are those same ol’ SE for NSAIDs (just a refresher here)?
GI ULCERATION/BLEEDS, impaired renal function, fluid retention, increased risk of CV issues.
If NSAIDS aren’t effective, what do we try next?
Glucocorticoids
Which glucocorticoid is used for gout?
Prednisone
What are those same ol’ SE for glucocorticoids (just a refresher here)?
GI ULCERATION, hyperglycemia, decreased wound healing, fluid retention
Re: Using glucocorticoids for gout. Do we normally do a short or long course of therapy? And why?
SHORT. That shit’s bad for you long term.
Using NSAIDs or glucocorticoids, how soon should the patient get relief?
within 24 hours
If NSAIDs and GCs aren’t cutting it, what is next for anti-inflammatory agents for gout?
Colchicine
Why don’t we use colchicine first?
Not a great risk/benefit ratio
True or false: Colchicine ONLY works on inflammation related to gout.
True
What is the MOA of colchicine?
Inhibits leukocyte infiltration –> prevents the destruction of lysosomal enzymes that cause the pain and inflammation in joint
SE of colchicine? What do we do if this happens?
GI (25%). Discontinue if occurs.
Why did the GI SE used to be 80% of patients?
We used to use higher doses
How do we dose colchicine these days? What is the max dose/24 hours?
1.2 mg loading dose
then
0.6 mg given 1 hour later
Max dose over 24 hours = 1.8 mg
Rare/serious SE of colchicine?
BM suppression, rhabdomyolysis, severe kidney or liver disease.
Patient education alert! What drug/food interaction do we need to tell patients about when taking colchicine?
NO GRAPEFRUIT
Colchicine drug/drug interactions
PGP or CYP3A4 drugs
Name three ways we PREVENT gout (hyperuricemia):
- Inhibit uric acid formation
- Increase uric acid excretion
- Convert uric acid
What is the prototype for drugs that inhibit uric acid formation?
Allopurinol (Zyloprim)
Also mentioned: Febuxostat (Uloric)
What is the medication mentioned that increases uric acid excretion?
Probenecid
How does probenecid work to increase UA excretion?
Works on renal tubules to increase UA excretion.
What else can probenecid be used for?
Used with abx because it manipulates excretion and allows drug to stay in the body longer
What are the two last ditch effort drugs mentioned that convert UA to help prevent gout?
Pegloticase and resburicase
they expensive and given IV tho
How does allopurinol work?
Decreases UA levels by inhibiting the enzyme that is required for UA formation.
What is tophi?
Deposits of uric acid crystals that develop into hard visible lumps that damage your joints and bones. Tophi can be microscopic or large and, though rarely, may need to be surgically removed.
How does allipurinol effect tophi? How long will you need to take it to see these results?
Decreases tophi that has already formed. Might take 6 months to see results!
How does allopurinol work with the kidneys?
Decreases risk of urate crystals in the kidneys
What can happen when patient first starts taking allopurinol for gout?
May increase acute gout attacks
When else might allopurinol be used?
As an adjunct medication with other issues that can cause an increase of UA (cancer, chemo, blood dycrasias)
Why can gout occur with chemo?
When cells die and break down, UA is released
What is the lab value of UA that is too high?
7 mg/dL
Most common SE of allopurinol?
GI
Rare and serious SE of allopurinol?
Hypersensitivity syndrome
Drug/drug interaction with allopurinol?
Warfarin (of course)
Patient teaching when taking allopurinol?
Increase fluids to flush kidneys!
Al needs to learn to flush to keep the toilet pure
What is osteoporosis?
Condition in which bone becomes weak and brittle
What t-score indicates osteoPENIA?
-1 to -2.5
What t-score indicates osteoPEROSIS?
-2.5 or mo’ negative
What is a FRAXX score?
10 year risk of experiencing a fracture
What three kinds of medications do we give for osteoporosis?
- Vitamin supplements
- Drugs that decrease bone resorption
- Drugs that increase bone formation
Name the drugs that decrease bone resorption (5)
- Calcitionin-Salmon
- Biphosphonates
- Estrogen replacement (Promarin)
- SERMs
- Denosumab (Prolia)
What is the one medication that increases bone formation?
Teriparatide, a form of parathyroid hormone (Forteo)
Let’s talk calcium. How much should you take/day, how should you take it, and which kind is best?
- 1200 mg/day (needs base on age and intake – this is for women age 51-70 usually)
- Take in divided doses (600 am, 600 pm)
- Calcium carbonate is best, highest percentage of Ca
Drug/food interactions with oxalic acid (Calcium oxalate)?
Spinach, rhubarb, swiss chard, beets
Drug/food interactions with phytic acid (Calcium phytate)?
Whole grain cereals, bran
Patient education for folks taking calcium oxalate or calcium phytate?
Separate meds from meals by 1 hour. There are a bunch of food-food interactions.
How much vitamin D should we be taking for osteoporosis prevention?
Oral supplement of 800 - 1000 mg daily
amounts may need to be increased if deficient
To what hormone does vitamin D act similarly?
Parathyroid hormone. Helps increase plasma Ca level.
How does vitamin D help increase plasma Ca level?
- Increases Ca absorption from bone
- Decreases Ca excretion from kidneys
- Increases Ca absorption from intestines
What is our drug that treats osteoporosis by preventing bone resorption?
Calcitonin-Salmon
How does Calcitonin-Salmon work to treat osteoporosis?
It keeps Ca in the bone and prevents pulling into the bloodstream
(Salmon won’t pull you into the ‘stream)
How is Calcitonin-Salmon given?
IN or SQ
ew, fish up yr nose
SE of Calcitonin-Salmon?
Nausea, nasal drying, increased malignancies (pulled in Canada)
(Snorting the The Great Canadian Salmon dries your nose and makes you nauseated.)
How do biphosphates work?
They prevent bone absorption by actually going into the bone and decreasing osteoclast activity
What are some other uses of biphosphates?
Padget’s disease, hypercalcemia of malignancy, bone mets
Biphosphate prototype?
Alendronate (Fosamax)
Alan uses a drone to get inside the bone to decrease osteoclast activity
How do you give alendronate?
PO
IV q 1 month or q 6 months (yay for compliance!)
What is a big thing we need to teach patients about taking alendronate?
NO FOOD with meds, Like, none. Not even coffee. Zero of the drug will be absorbed because it already has a low bioavailability.
Can carry on 30 minutes later.
True or false? Once alendronate is in the bone it is there for less than a month.
FALSE. It’s there for decades.
SE of alendronate?
Esophagitis is the big one.
Also, atypical fracture of the femur, musculoskeletal pain, ocular inflammation and osteonecrosis of the jaw (whaa?)
Re: Esophagitis as a SE of alendronate, what do we need to teach patients about taking this medication?
- Take on empty stomach 1st thing in the morning (no coffee!)
- Nothing to drink for 30 minutes
- Remain upright for 30 minutes
- Take with a full glass of water
- Don’t chew or suck on tablets (WHO DOES THAT ANYWAY)
What else should you take with alendronate?
Calcium and Vit D
This drug is no longer standard therapy for preventing bone resorption probably because it is made from preggo horse piss.
Premarin
PREgnant MARe urINe
How does premarin work?
Suppresses osteoclast proliferation (bone breakdown)
Estrogen is ______ protective.
Bone
Bad things that happen when you use pee from preggo horses?
Increased risk of BC and endometrial cancer, cholecystitis, MI, stroke
What does SERM stand for and what is the prototype?
Selective Estrogen Receptor Modifiers
Raloxifen (Evista)
MOA of SERMs/Raloxifen?
Block estrogen receptors on breast
cancer cells, but have estrogen effects
on non-breast cells
(Those non-breast cells can’t be RALOXin’)
SERMs/Raloxifen improve ____ _________ and reduce ________ fractures.
bone density, spinal
What other things do SERMs/Raloxifen improve?
Lipid profiles and CV risk
AE of SERMs/Raloxifen?
DVT and PE risk
True or false, SERMs/Raloxifen help with hot flashes
Nope, they can actually cause them
What is the SERM used to help prevent BC recurrence for estrogen positive BCs?
Tamoxifen (Nolvadex)
Can preggos take SERMs/Raloxifen?
No
Prototype for monoclonal antibody that decreases bone resorption.
Denosumab (Prolia)
MOA of denosumab?
Prevents the activation of RANK receptor.
RANK receptor is found of the surface of osteoclasts and their precursor cells. RANK stimulates the formation of osteoclasts.
SO this drug BLOCKS RANKL from activating RANK, thus inhibiting osteoclast formation. Also called a RANKL inhibitor.
How do we take denosumab?
SQ q 6 months
Take with Ca and Vit D
SE of denosumab?
Back pain, MS pain, pain in extremities, UTI, hypercholesteremia
What imbalance do you need to correct before starting denosumab?
hypocalcemia
What are the rare/serious SE of denosumab?
Serious infections, derm reactions, osteonecrosis of the jaw
What is the only drug that helps increase bone formation?
Teriparatide (Forteo)
What TF is teriparatide and what does it do?
A form of PTH made by recombinant DNA technology that increases bone deposits by osteoblasts.
How do we give teriparatide?
SQ
Some real bad things about teriparatide (2):
Expensive AF and increased risk of osteosarcoma
SE of teriparatide
Generally well tolerated but some nausea, back pain, and leg cramps. INITIAL orthostatic hypotension.
What is rheumatoid arthritis?
Autoimmune process where the immune system attacks synovial tissue.
The immune system activates what immune cells in RA? Name a few for me.
Macrophages, t-lymphocytes, cytokines, TNF
Types of anti-rheumatic drugs (3).
NSAIDS
Glucocorticoids
DMARDS
NSAIDs are great, but what happens with them and RA?
They give rapid relief but don’t prevent joint damage. Might need to use higher doses and people switch which ones they use.
How do glucocorticoids work with RA?
Rapid relief, slow progression. BUT long term use = toxic, so we have to do short courses.
Let’s talk DMARDs! Tell me about them, good and bad (4).
- Decrease joint destruction!
- More toxic than NSAIDs :(
- Come in a biologic and non-biologic form
- Patient should start these early – within 3 months of initial diagnosis
Prototype for non-biologic agent for DMARDs:
Methotrexate (Rhumatrex)
OMG y’all
We are almost done with this effing deck
What does methotrexate do?
Suppress immune system
How long does it take methotrexate to work?
3-6 months. Tx with NSAIDs until it kicks in.
What supplement should we take with methotrexate and why?
Folic Acid.
Methotrexate causes body to get rid of folate. Also, FA can help with GI side effects.
Why do we love methotrexate?
Efficacious in 80% of patients, low cost, relatively safe
Why do we hate methotrexate (4 SE) (3 shitty things)?
Hepatic fibrosis
BM suppression
GI ulceration
Pneumonitis
Reduced life expectancy from CV disease, infection, and certain cancers
Can preggos take methotrexate?
Nope. Category X
What do biologic DMARDs do?
Immunosuppressive drugs that target the specific parts of the inflammatory process
What parts of the inflammatory process do DMARDs target (3)?
– Tumor Necrosis Factor
– Promotes destruction of B cells
– Inhibits activation of T cells
All biologic DMARDs have this concern. Because of this, what should we do before starting these medications?
High risk of serious infections
• Test for TB, fungal infection (coccidioidomycosis), Hep B
How are biologics DMARDs made (THINK OF THE NAME, MY FRIEND)?
Made with recombinant DNA
For what other autoimmune infections are biologic DMARDs used?
Psoriasis, ankylosing spondylitis, Chron’s disease
Big drawback of biologics: DMARDs?
$$$ ($14,000-$35,000 per year)
Biologic DMARD prototype?
Etanercept (Enbrel)
What is the category of etanercept? Like, how does it work?
Tumor Necrosis Factor Antagonists
Main NBD SE of etanercept?
Injection site reactions
Special considerations when giving etanercept?
- Test for TB before tx
- Watch for Hep B reactivation
- No active infection
- No live vaccines
More serious SE of etanercept (Knowlton listed them as ‘risks’)?
Risk of heart failure, cancer, CNS disorders and rarely serious skin reactions
GUESS WHAT TIME IT (ALMOST) IS?!
SPRING HECKIN’ BREAK
Which of the following gout medications is used for an acute attack and may cause gastric upset?
Colchicine
These drugs used to be reserved for advanced rheumatoid arthritis, but are now being used within 3 months of rheumatoid arthritis diagnosis because they can delay joint degeneration.
DMARDs
What is calcium carbonate?
A calcium supplement
What is calcitrol?
Vitamin D therapy
What is alendronate (Fosamax)?
Biphosphonate
What is raloxifene (Evista)?
SERM
What is methotrexate (Rheumatrex)?
DMARD
non-biologic
What is the MOA of allopurinol (Zyloprim)?
Decreases uric acid levels
What does colchicine do?
Anti-inflammatory gout agent
Methotrexate can be used to treat rheumatoid arthritis. What other condition is it used for?
Cancer
