Drugs in Rheumatology

Question 1

Dosing regimen of Methotrexate

Answer 1

• Always has a once weekly dosing regimen
• 2.5mg tablets only
• Folic acid (taken on seperate day)
• “Methotrexate Monday” and “Folate Friday” may help you, and patients, remember the once weekly dosing regimen of these drugs.
• Avoid other anti-folate agents include: Methotrexate, Trimethoprim, Permetrexed and Proguan (anti-malarial).

Question 2

Side effects of Methotrexate

Answer 2

Cytopenia - Monitor full blood count and advise patients to report suspected infections and bruising.

Hepatotoxicity - Monitor liver function tests. Mild elevation is normal, but discontinue if they rise to more than 3x normal.

Renal impairment - Monitor renal function.

Pulmonary fibrosis - Take a baseline CXR. Advise patients to report any respiratory symptoms eg. dyspnoea/dry cough.

Teratogenicity - Advise patients to use contraception while taking methotrexate, and for 3 months after use.

Mucositis

Question 3

Side effects of Corticosteroids (name 3)

Answer 3

Cushing's syndrome
Osteoporosis
Retardation of growth
Thin skin, easy bruising
Immunosuppression
Cataracts and glaucoma
Oedema
Suppression of HPA axis
Teratogenic
Emotional disturbance (including psychosis
Rise in BP
Obesity (truncal)
Increased hair growth (hirsutism)
Diabetes mellitus
Striae

Avascular necrosis

Question 4

Side effects of NSAIDs

Answer 4

Indigestion
Peptic ulcer disease,
Increased risk of venous thrombo-embolus
Peripheral oedema
Slight increased risk of stroke and heart attack

Question 5

Side effects of Methotrexate

Answer 5

Gastro-intestinal disturbance
Folate deficiency - anaemia
Immunosuppression
Pulmonary fibrosis
Liver toxicity
Interstitial pneumonitis
Rash
Teratogenecity- Methotrexate is contraindicated during conception and pregnancy. The recommendation is a wash out of a few months (at least 3 months) before conception. In the event of a disease flare, low dose steroids are thought to be relatively safe. Note that high doses are associated with a small increased risk of the child having a cleft palate.

Question 6

Side effects of Sulfasalazine (DMARD)

Answer 6

Myelosuppression
Nausea
Rash
Oral ulcers
Decreased sperm count

Question 7

Side effects of Hydroxychloroquine

Answer 7

Retinopathy

Rash

Question 8

Side effects of Biologic therapy (e.g. etanercept, infliximab, adalimumab)

Answer 8

Immunosuppression
Reactivation of TB
Allergic reaction, reaction at infusion site

Question 9

Side effects of Gold

Answer 9

Myelosuppression
Renal toxicity (Nephrotic syndrome)
Mouth ulcers
Photosensitivity
Chrysiasis (skin discolouration)

Question 10

Ciclosporin

Answer 10

- used in management of psoriasis
side effects (5 H’s)
-  hypertrophy of the gums
- hypertrichosis
- hypertension
- hyperkalaemia 
- hyperglycaemia (diabetes).

Question 11

What must be monitored when prescribing Hydroxychloroquine

Answer 11

Visual acuity testing

Question 12

Methotrexate toxicity management

Answer 12

folinic acid