Musculoskeletal pharm Flashcards
Hydroxychloroquinine
Blocks TLR on APC
Ustekinumab
Human monoclonal antibody against IL-12 and IL-23
- Prevents Th1 cell formation
- Used in Psoriatic arthritis
Tocilizumab
Monoclonal antibody against IL-6 receptor on T-cells
- Prevents Th17 formation
- Used in RA
Infliximab, etanercept
Monoclonal antibody against TNF-alpha
Infliximab= used in RA, AS (Ankylosing spondylitis), PsA (Psoriatic arthritis)
Etanercept= used in RA, AS treatment
Adalimumab
Antibody against TNF-alpha
- Used in RA, AS
Belimumab
Anti-BLyS antibody
- used in SLE
Bisphosphonates
Mechanism of action is inhibition of osteoclast
Approved for prevention and treatment of osteoporosis
Oral forms: Alendronate, Risendronate, Ibandronate
- *Poorly absorbed and may cause esophagitis
- Daily, weekly, and monthly forms
Intravenous forms: Ibandronate and Zoledronic acid
SERMs
Raloxifene is approved for prevention and treatment of osteoporosis
Increases risk of thrombosis and fatal stroke but lowers risk of breast cancer
Increases BMD and reduces vertebral fracture but reduction is thought to not be as pronounced as those with bisphosphonates
- No direct comparison has been made
- Additive therapy does not provide much increased benefit given possible risks
Calcitonin
Binds to osteoclasts and prevents bone resorption
Available in subcutaneous, intramuscular, or intranasal formulations
Has small effect on BMD and low antifracture efficacy in comparison to bisphosphonates
Not used as first line treatment for osteoporosis
May have a role in treatment of bone pain following a fracture
PTH analogues
Teriparatide: Only PTH analogue available
- Used as subcutaneous daily injection
- Is the only anabolic therapy for osteoporosis
- Approved for prevention and treatment
Possible utility as combination therapy…
Should be used cautiously in patients with an increased risk of osteosarcoma, renal stones, gout, and renal failure
Check calcium, phosphorus, 25 hydroxy-vitamin D, alkaline phosphatase, uric acid, urine calcium prior to inititiation of medication
Denosumab
Humanized monoclonal antibody to RANK-L
Subcutaneous injection every six months
Approved in June 2010 for treatment of osteoporosis
Mediates osteoclast bone resorption
Rapid and significant increases in BMD and fracture risk reduction
Serious adverse events may be increased with Denosumab
Methotrexate
MOA: inhibits AICAR transformylase, thymidylate synthetase
- Enhances adenosine release–> antiinflammatory
- Folic acid inhibited (supplement during tx)
PK: 70% absorbed orally
- Polyglutaminiated
- Excreted in urine, bile
- 2-4 weeks to reach steady state
- 2.5-20 mg/ week; can also be given parenterally
Adverse reactions:
- GI (Nausea, mucosal ulcerations, liver enzyme elevations)
- RARE: Cirrhosis, hypersensitivity, pseudolymphomatous reaction (widespread lymph node enlargement)
Antimalarials for RA
Chloroquine
- Dose below 4 mg/kg
Hydroxychloroquine (safer, fewer side effects)
- Dose below 6.5 mg/kg
MOA: unclear
- Suppresses T-lymph response
- Decrease leukocyte chemotaxis
- Stabilize lysosomal membranes
- Inhibits DNA/RNA synthesis
- Traps free radicals in cell
PK:
- Rapidly absorbed
- 3-4 months to reach steady state
- 50% secreted unchanged in urine
- High tissue concentrations: mononucelar cells, pigmented tissue (eye), lysosomes
AEs:
- Frequent: GI, rashes
- Infrequent: retinal, neuromuscular
Sulfasalazine
Linkage of sulfapyridine, 5-aminosalicylic acid
- 30% absorbed in gut
MOA: suppresses lymphocyte/leukocyte functions
- Inhibits AICAR transformylase (like methotrexate); increases adenosine release
- Reduces activation of NF-kB (thus reducing expression of pro-inflammatory genes)
AEs:
- GI
- Sulfa allergies
RA: Combination therapy before biologics
Methotrexate + SSZ + HCQ
- (could use azathioprine, cyclosporine, leflunomide- RARE)