FINAL arthritis gout and muscle relaxants Flashcards
what would for a pt that had arthritis that was non responsive to NSAIDS or we were worried about GI issues
nonacetylate salicylates
same with pt on WARFARIN
when would we use intraarticular glucocorticoids
KNEE OA
not hip
adjunct inj
hyalgan synvisc supartz euflexxa gel-one
all used for
these are intraarticular hyaluronic acid all used for knee OA
Hulk Hogan
into synergyvic
and her supartz
wants to euflexxa
or gel-one
DMARDS used for
RA
AS
Psoriatric arthritis
psoriasis
also crohn’s
UC
NOT OA!!!!! immune not inflamamtion
used to give prednisone first to delay use of DMARDs but now
usually what order of drugs do we use in RA
1st DMARD
add second
NSAIDS prednisone
maybe a biologic
dosing of methotrexate/rhematrex
7.5-25 mg SC/IM A WEEK!!!!!!!!!
NOT DAILY don’t want to wipe out immune system
MOA of methotrexate
dihydrofolate reducatse inhibitor that inhibits DNA synthesis
a lot of proliferation and cytokines can be stopped (can be used for cancer)
onset of methotrexate
1-2 months
w/ RENAL elimination
SE of methotrexate
myelosupression
N/V/D
Ulcers
stomatitis
dose related hepatotox
pulm tox
monitoring needed for metotrexate
CBC
SCr
LFTs
montly for 6 months
then every 1-2 more
when would you check for liver damage with methotrexate
need LFTs regularly
liver biopsy after 4 g
then 1.5 g after that
methotrexate can be used with what DMARD
hydroxychloroquin and sulfasalizine
NOT leufunomide
avoid MTX in
pregnant
liver disease
immunodeficiency synfromes
leflunomide
slow onset long half life
1-3montjs and 1/2 life 14-15 days
when to use leflunomide
alt to methotrexate because of hepatotox
monitoring for leflunomide **
CBC
SCr
LFTs
montly for 6 months
then every 1-2 more
leflunomide should not be used in
pregnant pt
this can be used for overdose with leflunomide
cholestyramine questran
whart do you need before starting hydroxychloroquine
opthalmic exam to monitor effects
interluken DMARDS
ana kinra gusselkumab usetekinumab ixekizumab secukinumab tocilizumab
Anna and Guss use Icky Sec Tock
they are inter each other but Luke wants Ana
TNF biologic
Golimumab Adalimumab etanercept certolizumab infliximab
Goli named Ada (all libms) entanercepted CertainLIZ
inflicting Abb and dyyb
ADA BOY! TNF FTW
other biologics
Apparently Ritu and Aba like Tofu and Vodo
Apremilast Abatacept Rituximab Tofacitinib Vedolizumab
Other weirdos like tofu and vodo
biologics that can be used for AS
Ixekizumab
Secukinumab
you can not use this TNF I for IBD like the rest
etanercept
common ADE with TNF I
Malignancies, new onset psoriasis, invasive fungal infection, sepsis, TB, Hep B react
what do you need to do before starting someone on a tNFI
hepatitis panel
check TB
check flu vaccinations
get baseline LFTs
DDI TNFI
•Liver toxic, lymphoma: Cannot give with other TNF-a inhibitors
probably need to give this TNF I with MXT why?
infliximab
contains mouse parts and we can develop AB
need to avoid these two TNFI in CHF
inflixi and entanercept
TNFI with longest half life
Goali
IL-1 antagonist that is : $$$$, hardly used (maybe consider in TB patient??)
anakinra
NO reactivation TB
NEVER combine IL drug with
TNFi or IL-drug with other IL-drug
Wont be able to fight infection, sepsis risk
no renal or dose adjustments are in needed in all but one ILI
tocliizumab
it can cili-u
Potential to cause FATAL anaphylaxis
•Can cause neutropenia, LFT changes, decrease platelets. If LFTs>1-3x ULN, decrease dose. If ANC <500 d/c. IF platelets <50K d/c
this ILI can CAUSE IBD
secukinumab
IBD will shut down the sec
which ILI can be used for plaque psoriasis
guselkumab
when would we use Tofascitinib
: mod-severe monotherapy or combine with NON-biologic DMARDS in pts who fail MXT
when would we use tofacitinib
Hypotension, HA: can cause neutropenia, decreased WBCs, decreased hemoglobin
CI with tofacitinib (xelijanz)
CYP3A4/2C19 drugs will INCREASE Xeljanz. Reduce dose to 5mg when on ketoconazole, fluconazole.
•Do NOT combine with IL-drug, TNF drug, or other “other biologic”
•Avoid with azathioprine (drug that prevents organ rejection), tacrolimus, cyclosporine (increased immunosuppression risk)
monitoring and dose adj needed for tofacitinib
RENAL and HEPATIC:
reduce dose CrCl <40 and hepatic impairment, CONTRAINDICATED in SEVERE Hepatic dysfunction
•Monitor CBC: d/c if lymphocytes <500 or ANC <500. If Hgb <8 interrupt therapy until it normalizes
abatacept
prevents full T cell activation
check PPD
IV or subQ
don’t combine wiht other biologics
rituximab MOA
chimeric monoclonal AB that targets CD20 B lymphocytes.
adj needed for rituximab
NO NEED TO TB SCREEN
No need to dose adjust renal/hepatic
rituximab indications
benefits RA pts refractory to TNF-a inhibitors. Can combine with MXT
PD-E4 inhibitor, increase cAMP, diminished T-cell secretion cytokines
apremilast
psych caution needed with this biologic
apremilast
otezla
CYP! Inducers will DECREASE this biologic
apremilast conc
renal adjustment needed for apremilast
oral, dose adjust renal CrCl <30
Need to titrate up oral dose!!
this drug inhibits zanthine oxidase which in turn decreases uric acid production
allopurinol
ALOE PERANA AND FAT BOXER
allopurinol must be started with
Colchicine
how does colchicine work
DOES NOT EFFECT UA metabaolism
inhibits leukocytes migration
this is an anti-inflammatory with no analgesic effect
abatacept (Orencia)
selective co-stimulation modulator:
Fragment of Fc domain of human IgG1 & extracell domain of human cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4)
Prevents full T-cell activation
Abba loves tofu and rita and Apremi but doesn’t like Tea
prevents full T
SE common to colchicine
N/V/D 50-80% of pts
CI in PUD
bone marrow supression
DOES NOT EFFECT URIC ACID METABOLISM
ADE with allopurinols
can cause a gout attack
can cause rash (more common if on PCN)
elukopenia diarrhea nausea increased LFTs increase levels of azathioprine
DDI with allopurinole
can cause immune suppression want to avoid abnx and theophylline
can increase INR if on warfarin
dosing adjustments for allopurinole
renal
which gout drug would you not want to take with ETOH
colchicine
will increase GI tox
also do not take with grapefruit or erythromycin
this biologic that targets CD20 lymphocytes does not need to be TB screened and can last 3-6 months after infusions on day 1 and 15
rituximab
what is unique about Tofacitinib
it is taken ORALLY
JAK inhibitor
this drug inhibits pDE4
what is something that’s exciting about this drug
apremilast
ORALLY
1st line for gout
indomethacin
hwo does indomethacin work and what is in CI with
works to inhibit COX 1
CI in GI ades
renal insufficiency
or PUD
what are the ADE of probenacid
GI irritation
rash
hypersensitivity
kidney stone formation
how does probenacid need to be given
with food or antiacids
why can’t you give ASA with probenacid
it slows UA renal secretion and increases UA blood levels
how does febuxostat work
non-purine xanthine oxidase inhibitor
which means it decrease ua PRODUCTION
pegloticase
inactivates uric acod
baclofen mOA
acts on GABAb causes hyperol thru increase K conductance
inhibits excitatory NT
tis drug is a skeletal muscle relaxant used to treat spasticity secondary to MS
baclofen
when your back is hurten b/c of MS
what population is baclofen CI in
seizures
DM
caution in elderly
this skeletal muscle relaxant has a similar structure to TCA like amityptyline and can be used for acute spasms trauma or sprains
cyclobenzaprine
flexeril
CI of cyclobenzapine
this is an ANTICHOLINERGIC CI in CV sz galucoma seizure disorder
ADE of cyclobenzapine
sedation confusion visual hallucination
this drug blocks Ca release from SR similar to PHT
dantrolene
dantrolene can be used to treat
malignant hypothermia
m spasticity
dantrolene is CI
liver CD hepatitis muscle weakness sedation
do not give dantrolene if your pt is on
CCB or ESTROGEN
this sekeletal muscle relaxant is a lapha 2 agonsit
tizanidine
ADE of tizanidine
hypotension
drowsniess
dry mouth
methyprenisolone
intra-articular glucocorticoid used at the knee and inj for OA
methyprenisolone is CI 2/
NSAIDS
colchicine
