Medicines Knowledge Week 2 (Adalimumab, Celecoxib, Methotrexate, Allopurinol, Mesalazine)

Question 1

Adalimumab drug class

Answer 1

TNF-alpha antagonists

Question 2

Adalimumab indication

Answer 2

Rheumatoid arthritis (use with methotrexate, if possible)

Crohn’s disease

Ulcerative Colitis

Psoriatic arthritis

Ankylosing spondylitis

Question 3

Adalimumab dosage range and timing

Answer 3

Rheumatoid or psoriatic arthritis, ankylosing spondylitis

• SC 40mg once every 2 weeks

> Rheumatoid arthritis, patients not taking methotrexate may benefit from an increased dose of 40 mg once a week or 80 mg every 2 weeks.

Psoriasis

• SC, 80 mg then, starting 1 week later, 40 mg once every 2 weeks.

> if no response after 16 weeks consider stopping treatment

Question 4

Adalimumab Counselling (3 marks)

Answer 4

Contact your doctor urgently if you have persistent fever, other signs of infection, or bruising or bleeding.

Some vaccines should not be given to people receiving a TNF-alpha antagonist. Check with your doctor before receiving a vaccine.

Once you take this medication out of the refrigerator, leave it at room temperature for 15 to 30 minutes before injecting. Do not warm humira in any other way, For example, do not warm it in the microwave or in it hot water.

In rheumatoid arthritis and psoriasis, initial response to treatment occurs within 1–2 weeks, with maximum response by 12–16 weeks

Question 5

Adalimumab monitoring (2 marks)

Answer 5

Check complete blood count, ALT, AST and creatinine before treatment

Check patients for skin cancer before starting and during treatment

After stopping treatment with an TNF-alpha antagonist, continue to consider the possibility of their adverse effects for several months.

Question 6

Celecoxib drug class

Answer 6

Non steroidal anti-inflammatory

Question 7

Celecoxib indication

Answer 7

Rheumatoid arthritis

Osteoarthritis

Ankylosing spondilitis

Pain due to dysmenorrhoea or injury

Question 8

Celecoxib dosage range and timing

Answer 8

Ankylosing spondylitis, osteoarthritis

• Adult, oral, up to 200 mg daily, in 1 or 2 doses.

Rheumatoid arthritis

• Adult, oral 100 mg twice daily. May be increased to 200 mg twice daily (short term)

Period pain

• Adult, oral 400 mg daily in 1 or 2 doses on the first day, then 200 mg once or twice daily if needed; maximum 5 days treatment.

Question 9

Celecoxib counselling

Answer 9

It is not important whether you take your doses before or after meals.

If you forget to take a dose, take it as soon as you remember unless it is nearly time for your next dose, in which case leave out the missed dose. Do not take two doses together to make up for a missed dose.

Do not take aspirin for pain relief as it will increase the risk of side effects with this medicine.

Don’t take this medicine if you are dehydrated, for example due to vomiting or diarrhoea, because it might increase the likelihood of side effects, particularly for children and elderly people

Question 10

Celecoxib monitoring

Answer 10

Monitor for adverse effects such as swollen ankles, difficulty in breathing, chest pain, black stools or dark coloured vomit. If any of these side effects occur, stop taking the medicine and tell your doctor

Monitor blood pressure, renal and liver function, signs and symptoms of GI bleeding in patients who have a higher risk of these side effects (elderly, heart failure, renal toxicity, liver toxicity).

Question 11

Methotrexate drug class

Answer 11

Immunomodulator/immunosupressant

Question 12

Methotrexate indication

Answer 12

Rheumatoid arthritis

Psoriasis (severe, disabling)

Crohn’s disease

Juvenile idiopathic arthritis

Ectopic pregnancy

Question 13

Methotrexate dosage range and timing

Answer 13

RA, psoriasis

• Oral/SC/IM, initially 10–15 mg once a week, adjust dose according to response.
• Usual maintenance 10–25 mg once a week (maximum, oral 30 mg; SC/IM 25 mg).

Juvenile idiopathic arthritis

• Oral/SC/IM, 10–20 mg/m2 (maximum 25 mg) once a week.

Chrons disease

• Adult, IM/SC, induction of remission, 25 mg once a week; usual maintenance, IM/SC/oral 15–25 mg once a week.

Question 14

Methotrexate counselling

Answer 14

Take this medication strictly as directed. It should be taken once a week on the same day each week; it must not be taken every day.

Drinking alcohol can increase the side effects of methotrexate. Limit consumption, eg avoid drinking more than 1 standard drink in a day for women or 1–2 standard drinks in a day for men; discuss this with your doctor if it is a problem for you.

Avoid sun exposure, wear protective clothing and use sunscreen as methotrexate may make you more sensitive to sunlight.

Tell your doctor and pharmacist that you are taking methotrexate before starting any new medicines.

Folic acid is required when taking this medication to reduce gastrointestinal side effects and to reduce elevated liver enzymes. It is taken 24 hours after your methotrexate dose.

Question 15

Methotrexate monitoring

Answer 15

• Monitor complete blood count, renal and liver function at baseline then regularly as determined by specialist (eg every 2–4 weeks for the first 3 months, then every 3 months);

> check more frequently at start of treatment, during dose titration or change of route and if clinically indicated.

• Reduce dose or stop treatment if leucopenia or thrombocytopenia develop
• Monitor for side effects such as nausea, mouth ulcers, bruising, diarrhoea or signs of infection. Tell your doctor if these side effects occur.

Question 16

Allopuronol drug class

Answer 16

Xanthine oxidase inhibitor

Question 17

Allopurinol indication

Answer 17

Chronic symptomatic hyperuricaemia (eg gout or tophi, urate nephrolithiasis or acute uric acid nephropathy)

Hyperuricaemia secondary to disease, chemotherapy or radiotherapy, seek specialist advice.

Question 18

Allopurinol dosage range and timing

Answer 18

Chronic symptomatic hyperuricaemia

Start with a low dose (no more than 100 mg daily) and slowly increase at monthly intervals (eg by 50–100 mg daily) aiming for serum urate concentration <0.36 mmol/L (0.3 mmol/L if tophi present).

• Maintenance, oral, usually 300–600 mg (maximum 900 mg) daily, irrespective of renal function.

> Take this medicine with or shortly after food to reduce the possibility of stomach upset.

Question 19

Allopurinol counselling

Answer 19

This medicine may make you feel dizzy or drowsy; do not drive or operate machinery if you are affected.

If you develop a rash, swollen lips or mouth, persistent fever or sore throat, stop taking this medicine and tell your doctor immediately.

You will probably get more gout attacks (flares) in the first few months of taking this medicine. This doesn’t mean the treatment isn’t working. This medicine reduces urate in your body and when it’s low enough, gradually flares will improve and eventually stop and tophi will disappear if you keep on taking it.

Question 20

Allopurinol monitoring

Answer 20

Monitoring of urate in your blood is required to make sure that your dose is adequate, your doctor will do this.

Measure renal and liver function at baseline; repeat regularly, especially during dose titration

Measure serum urate every 2–5 weeks during dose titration; aim for serum urate <0.36 mmol/L (<0.3 mmol/L if tophi present); then measure every 6 months during maintenance

Monitor frequency of gout attacks, and if applicable tophi size

Question 21

Mesalazine drug class

Answer 21

5-aminosalicylate

Question 22

Mesalazine indication

Answer 22

Inflammtory Bowel Disease

• Ulcerative colitis
• Chron’s disease

Question 23

Mesalazine dosage range and timing

Answer 23

UC adult

> Acute: Mesasal® tablet, oral 500 mg 3 times daily.

> Maintanence: Mesasal® tablet, oral 250 mg 3 times daily.

Crohn’s disease, adult

> Acute: Mesasal® tablet, oral 500 mg 3 times daily.

> Maintanence: Mesasal® tablet, oral 250 mg 3 times daily.

mesasal comes in 250mg only and take tablets half an hour before food

Question 24

Mesalazine counselling

Answer 24

Swallow tablets or granules whole without chewing or crushing them.

Mesasal®: take tablets at least half an hour before food.

It is safe to drink alcohol in moderation while you are on this medication but it might aggravate any nausea.

Question 25

Mesalazine monitoring

Answer 25

Monitor renal and liver function at baseline; repeat every 3 months in the first year, then every 6 months.

Monitor for adverse effects such as rash, headache, diarrhoea and hepatitis