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424 Pharmacology > Joint & Bone health > Flashcards

Joint & Bone health Flashcards

1
Q

What are the indications of the following medications?

  • Xanthine oxidase inhibitors: allopurinol, febuxosta
  • Colchicine
  • Probenecid
  • Prednisone
A
  • Xanthine oxidase inhibitors: allopurinol, febuxosta: chronic gout
  • Colchicine: acute gout
  • Probenecid: chronic gout
  • Prednisone: acute gout, RA
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2
Q

What are the indications of the following medications?

  • Acetaminophen
  • NSAIDs
  • Tramadol
A
  • Acetaminophen: mild to moderate OA
  • NSAIDs: mild to moderate OA, RA
  • Tramadol: consider when pain associated with OA progresses past responsivenes to APAP and NSAIDS
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3
Q

What are the indications of the following medications?

  • Methotrexate
  • TMF inhibitors (Rituximab, abatacept)
A
  • Methotrexate: RA
  • TMF inhibitors (Rituximab, abatacept): RA
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4
Q

Bisphosphonates

Indications

A
  • osteoporosis
  • high fracture risk (long-term glucocorticoid tx, high FRAX score)
  • hypercalcemia
  • metastatic bone disease
  • paget disease
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5
Q

Bisphosphonates

Formulations & prescribing considerations

A
  • Risedronate (Actonel) inhibits bone resorption without inhibiting bone formation - 35mg oral once weekly or 150mg oral once monthly
  • Alendronate (Fosamax): highly selective inhibitor of bone resorption - 70mg oral once weekly
  • Ibandronate (Boniva): lack of evidence for prevention of hip or non-vertebral fracture
  • Zoledronic acid (Reclast): 5mg IV once yearly
    • Higher risk of renal toxicity
    • Check creatinine before each dose
    • Push fluids before and after each dose
    • Acetaminophen after infusion may reduce acute-phase reaction
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6
Q

Xanthine oxidase inhibitors

allopurinol, febuxostat

MOA

A

decreases uric acid levels by selectively inhibiting xanthine oxidase (enzyme responsible for conversion of hypoxanthine to uric acid), reducing the risk of crystallization and gout attack; allows for biosynthesis of vital purines

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7
Q

Xanthine oxidase inhibitors

allopurinol, febuxostat

Prescribing considerations

A
  • Febuxostat may increase risk for cardiac related deaths - first line is allopurinol
  • Administer with NSAID or colchine for up to 6 months to prevent gout flare
  • Allopurinol: prescribe an alternative agent for Korean patients with stage 3 or worse CKD or Han Chinese and Thai patients should receive genetic testing for HLA-B 5801 allele - may cause severe cutaneous adverse reaction
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8
Q

Xanthine oxidase inhibitors

allopurinol, febuxostat

Avoid, caution, pregnancy, peds

A
  • Avoid: severe hepatic dysfunction
  • Caution: renal impairment - can be used
  • Pregnancy: avoid; lactation: allopurinol with caution
  • Peds: 6+ related to hyperuricemia from cancer therapy
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9
Q

Xanthine oxidase inhibitors

allopurinol, febuxostat

Drug interactions, what is the goal uric acid level while on this therapy?

A
  • Interactions
    • azathioprine, mercaptopurine, theophylline
    • Thiazides - risk for toxicity in older adults
  • Monitoring: Aim for serum uric acid level of less than 6 mg/dL
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10
Q

Xanthine oxidase inhibitors

allopurinol, febuxostat

Adverse fx (5, 2 rare)

A
  • Maculopapular skin rash
  • Arthralgias
  • Nausea
  • Diarrhea
  • Elevated transaminases
  • Rare: hypersensitivity, hepatotoxicity
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11
Q

Colchicine

MOA, how long before this medication takes effect?

A
  • inhibits activation, degranulation and migration of neutrophils to the area of a gout attack, decreasing inflammation and pain associated with a gout attack; does not impact purine metabolism
  • Takes 18-24 hours to take effect, full effects at 48 hours
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12
Q

Colchicine

Caution, pregnancy/lactation, peds

A
  • Caution: renal and hepatic impairment, elderly
  • Pregnancy/lactation: caution
  • Peds: 16+
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13
Q

Colchicine

Interactions

A
  • Thiazides - risk for toxicity in older adults
  • P450 medications
  • grapefruit juice
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14
Q

Colchicine

Adverse fx (7, 5 rare)

A
  • GI: Nausea, GI disturbance, diarrhea, abd pain, malabsorption of B12
  • Other: Neuropathy, weakness
  • Rare: agranulocytosis, aplastic anemia, alopecia, hepatic dysfunction and hepatotoxicity
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15
Q

Probenecid

MOA

A

increases excretion of serum uric acid by competitively inhibiting reabsorption of uric acid at the proximal convoluted tubule

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16
Q

Probenecid

Which population is this the drug of choice for?

Avoid, drug interactions, pregnancy/lactation, peds

A
  • Drug of choice for older adults
  • Avoid: blood dyscrasias, CrCl less than 30, G6PD deficiency, sulfa allergy
  • Interaction: aspirin
  • Pregnancy/lactation: OK
  • Peds: 2+
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17
Q

Probenecid

Adverse fx (11, 2 rare)

A
  • CNS: headache, dizziness
  • GI: anorexia, N/V, gingival soreness
  • Skin/bones/joints: dermatitis, pruritis, flushing, gout exacerbation
  • Other: Urinary frequency, fever
  • Rare: anaphylaxis, blood dyscrasias
18
Q

Acetaminophen

MOA, patient education/prescribing considerations

A
  • MOA: decreased prostaglandin synthesis - analgesic and antipyretic not anti-inflammatory
  • Does not affect COX, so does not affect platelet aggregation or cause GI irritation
  • Takes 1 week for patients to see benefits, better to take routinely
19
Q

Acetaminophen

Avoid, pregnancy/lactation, peds, when to d/c, what monitoring is needed with long term use?

A
  • Avoid: severe hepatic impairment and severe active liver disease
  • Pregnancy/lactation: OK
  • Peds: OK
  • D/c if skin reaction develops
  • Liver function for high dose or long-term therapy
20
Q

Acetaminophen

Adverse fx (3)

A
  • Skin rash
  • Dizziness
  • Rare: hypersensitivity reactions
21
Q

NSAIDs

Ibuprofen, naproxen, voltaren gel

MOA

A

exerts anti-inflammatory action by inhibiting conversion of arachidonic acid to prostaglandin, prostacyclin and thromboxanes (mediators of pain and inflammation)

22
Q

NSAIDs

Ibuprofen, naproxen, voltaren gel

Avoid, caution, pregnancy/lactation, peds, which is preferred for the elderly and why?; black box warning

A
  • Avoid: GFR less than 30
  • Caution: cardiovascular disease, elderly patients, renal and hepatic impairment
  • Pregnancy: avoid; lactation: compatible
  • Peds: 6 months +; ASA not in children with viral infection d/t risk for Reye’s syndrome
  • Voltaren gel is preferred in elderly due to decreased systemic fx
  • BBW: increased risk for thrombotic events; serious GI bleeding, ulceration and perforations
23
Q

NSAIDs

Ibuprofen, naproxen, voltaren gel

Adverse fx (9)

A
  • GI: GI disturbances, dyspepsia
  • Edema
  • Dizziness
  • Skin rash
  • Elevated transaminases
  • HTN
  • Bleeding due to reversibly impacting platelet aggregation
  • Indomethacin: may aggravate depression or other psychiatric disturbances
24
Q

Bisphosphonates

Risedronate, alendronate, ibandronate, zoledronic acid

MOA

A

inhibit bone resorption by reducing osteoclast number and function

25
Q

Bisphosphonates

Risendronate, alendronate, ibandronate, zoledronic acid

Prescribing considerations/patient education

A
  • given on an empty stomach with eight ounces of water to enhance absorption and stay upright for at least 30 minutes (Boniva is 1 hour); ensure patient is also taking calcium and vitamin D
  • First-line for postmenopausal women with osteoporosis
  • First-line therapy for men older than 70 with osteoporosis
  • Fracture risk high after 5 years - consider changing to alternative therapy or extending for up to 10 years
  • Consider drug holiday after 5 years if bone mineral density is stable
  • High risk patients: caucasian, asian, history of eating disorders, long term steroid or thyroid medications
  • Correct preexisting Vit D deficiency or hypocalcemia before starting
  • IV can be used for those with GI intolerance
26
Q

Bisphosphonates

Risendronate, alendronate, ibandronate, zoledronic acid

caution, avoid, contraindication

A
  • Caution: moderate to severe kidney disease, upper GI pathology, bariatric surgery
  • Avoid: CrCl less than 35
  • Contraindication: hypocalcemia, delayed esophageal emptying, inability to stand/sit upright for 30 minutes, increased risk of aspiration
27
Q

Bisphosphonates

Risendronate, alendronate, ibandronate, zoledronic acid

What medication alters the bioavailability of alendronate?

A

Ranitidine doubles the bioavailability

28
Q

Bisphosphonates

Risendronate, alendronate, ibandronate, zoledronic acid

Adverse fx (17)

A
  • GI: upper GI mucosa irritation, diarrhea, constipation, flatulence, N/V; abd pain, dyspepsia
  • Bones/Joints: Femur fractures (higher risk in therapy past 5 years), severe bone, joint, muscle pain; jaw osteonecrosis, arthralgia, myalgia
  • Other: Hypocalcemia, hypophosphatemia, HA, rash, a.fib
29
Q

Prednisone

MOA, avoid, caution, other considerations, pregnancy/lactation, peds

A
  • MOA: decreases inflammation by suppression migration of polymorphonuclear leukocytes and reversing increased capillary permeability
  • Avoid: uncontrolled active infections
  • Caution: diabetic patients, active GI disease, renal and hepatic impairment
  • Other considerations: prolonged use may lead to adrenal suppression and immunosuppression
  • Pregnancy/lactation: caution
  • Peds: OK
30
Q

Prednisone

Adverse fx (6)

Adverse fx with chronic use (6)

A
  • Hypertension
  • Insomnia
  • Mood changes
  • Increased appetite
  • Glucose intolerance
  • Peptic ulcer
  • Chronic use: cutaneous atrophy, cataracts, glaucoma, osteoporosis, growth suppression, Cushing’s syndrome; use calcium and vitamin D
31
Q

Tramadol

MOA

A

Mu opioid receptor agonist that inhibits ascending pain pathways; inhibits reuptake of serotonin and norepinephrine

32
Q

Tramadol

avoid, caution, peds, drug interactions

A
  • Avoid: hx of seizures (lowers seizure threshold)
  • Caution: substance abuse hx, renal and hepatic impairment, elderly
  • Peds: caution
  • Interactions: other CNS depressants, serotonergic agents (r/f serotonin syndrome)
33
Q

Tramadol

Adverse fx (6)

A
  • CNS fx: Dizziness, drowsiness, dependency, euphoria
  • Sweating
  • Constipation
34
Q

Disease modifying antirheumatic drugs (DMARDs): methotrexate

MOA, prescribing considerations

A
  • folic acid antagonist; thought to affect leukocyte suppression, decreasing inflammation that results from immunologic byproducts
  • Considerations
    • Need to give folic acid supplementation
    • Time to response = 3-8 weeks - need to supplement with another treatment option until the medication can take effect
35
Q

Disease modifying antirheumatic drugs (DMARDs): methotrexate

Avoid, caution, black box warning, pregnancy/lactation

A
  • Avoid: blood dyscrasias
  • Caution: renal and hepatic impairment
  • BBW: risk of hepatotoxicity, renal impairment, pneumonitis, bone marrow suppression, GI toxicity, active stomatitis, dermatology reactions, opportunistic infections
  • Pregnancy/lactation: avoid
36
Q

Disease modifying antirheumatic drugs (DMARDs): methotrexate

Adverse fx (9)

A
  • GI: Nausea, diarrhea, oral ulcers
  • Skin/hair: photosensitivity, alopecia, skin rash
  • Other: Arthralgias, dizziness, increased serum transaminases
37
Q

Biologic DMARDS - TMF inhibitors: Rituximab (Rituxan), abatacept (Orencia)

MOA

A

inactivates circulating TNF-alpha, reducing the chemotactic fx of TNF-alpha by reducing IL-6 and CRP; results in reduced infiltration of inflammatory cells into the joint; cell lysis occurs

38
Q

Biologic DMARDS - TMF inhibitors: Rituximab (Rituxan), abatacept (Orencia)

What needs to be updated before initiating therapy? Any other considerations?

A

update immunizations before initiating, any live immunizations should be given 3 months before initiating therapy

39
Q

Biologic DMARDS - TMF inhibitors: Rituximab (Rituxan), abatacept (Orencia)

Caution, pregnancy/lactation, peds

A
  • Caution: new/recurrent infections
  • Pregnancy/lactation: limited data
  • Peds: 2+
40
Q

Biologic DMARDS - TMF inhibitors: Rituximab (Rituxan), abatacept (Orencia)

Adverse fx (6)

A
  • Injection site reactions
  • Infusion reaction
  • Infections
  • Dizziness
  • Headaches
  • nausea

424 Pharmacology (12 decks)

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