1. increased uric acid production 2. decreased uric acid excretion 3. increased intake of purine-containing foods

Osteoporosis, Gout, RA Flashcards by Sarah R

3 causes for gout

increased uric acid production
decreased uric acid excretion
increased intake of purine-containing foods

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acute gout attacks are classified as how many a year? and what type of meds should they be on?

< 3 attacks/year

should be on ANTI INFLAMMATORY AGENTS

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what is our 1st line tx for acute gout attack?

NSAIDs

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name some of the main adverse effects of NSAID use

GI ulceration/bleeding
impair renal function
CV events

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what is 2nd line tx for acute gout attack? + what’s the prototype?

glucocorticoids : PREDNISONE

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when treating acute gout attack (NSAIDs + glucocorticoids) when would we want to see results (decreased pain + inflammation)?

within 24 hours ◡̈

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what’s our 3rd choice tx for acute gout attack?

ColChiCine

= aCute

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what is our anti-inflammatory prototype for acute gout attack? (3rd choice, if NSAIDs and steroids are out)

colchicine

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what is the unique thing about colchicine?

anti-inflammatory effects ONLY with gout

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what is the MOA of colchicine?

inhibits leukocyte infiltration –> prevents destructive lysosomal enzymes

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what is the MAIN adverse effect of colchicine and what should we do if this occurs?

GI effects –> discontinue drug!!!

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describe the dosing for colchicine (initial + max)

1.2mg loading dose –> 0.6mg 1 hour later

MAX: 1.8mg/day

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what are the 4 serious/rare AE of colchicine?

bone marrow suppression
rhabdomyolysis
severe kidney disease
severe liver disease

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drug-food interaction with colchicine?

grapefruit juice

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if someone has > 3 gout attacks/year, what medication plan should they be on?

PREVENTION of gout (allopurinol)

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what is our prototype for drugs that inhibit uric acid formation?

allopurinol

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in addition to reducing uric acid levels, allopurinol has 2 more actions r/t gout

decrease tophi that’s already formed

2. decrease risk of urate crystals in kidneys

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what is allopurinol known to do at the START of therapy?

can increase acute gout attacks

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SE of allopurinol

GI (mild)

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rare/serious AE of allopurinol

hypersensitivity syndrome

“ALL PUR drugs are sensitive”

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drug-drug interaction with allopurinol

warfarin

“ALL PUR drugs are SENSITIVE (AE) and don’t like WAR[farin]”

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what patient education should we include with allopurinol therapy?

H2O H2O H2O!!!

increase fluid intake to flush out kidneys

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what is our “least invasive”/starting point for therapy for osteoporosis + also what all other drug therapies should be paired with?

vitamin supplementation: vit D + calcium

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for osteoporosis therapy, what are the 5 classes of drugs that decrease bone resorption (osteoClast)?

calcitonin-salmon
biphosphonates*
estrogen replacement
SERMs
Denosumab

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for osteoporosis therapy, what is the prototype for drugs that increase bone formation (osteoBlast)?

teriparatide "teri has this bone para ti (for you)" "teri is super generous and wants to help you increase your bone formation"

vitamin supplementation for osteoporosis prevention + tx is based on what?

age + intake

how much calcium/day? (woman 51-70yrs)

1200mg

what's the unique thing about calcium dosing?

body can only absorb 600mg at a time, so dosing should be divided *calcium carbonate has HIGHEST % of Ca ◡̈ *

what food interactions should you know about with calcium? how can we work around this?

oxalic acid spinach, beets, rhubarb, swiss chard, brain, whole grains *separate intake of Ca + these foods by 1 hour*

how much vitamin D should be supplemented daily?

800-1000mg/day

what is the MOA of calcitonin-salmon?

prevents bone resorption (osteoClast activity) : keeps calcium in the bone + prevents pulling into bloodstream "the salmon prevents you from being pulled into the stream"

routes for calcitonin-salmon?

intranasal | SQ

SE of calcitonin-salmon

nasal drying, nausea, increased malignancies (canada) *3rd choice drug* "snorting salmon through your nose causes you to be nauseated with a dry nose and get malignancies if you go to canada"

what's our gold star and 1st choice drug for TREATMENT of osteoporosis? + what is prototype?

biphosphonates : alendronate

MOA of biphosphonates

prevents bone resorption + undergoes incorporation into bone (so effects of this drug can last a long time)

what is the ending of biphosphonates / how can we recognize them?

"____ronates"

patient education with PO alendronate (4 things)

1. don't take with ANY food - none will be absorbed 2. take with FULL glass of H2O 3. remain upright for 30 minutes - can cause severe esophagitis! 4. don't chew or suck on tablets

what is most common SE of alendronate?

esophagitis | stay upright 30 mins after PO admin

AE of alendronate (4)

1. atypical femur fractures 2. musculoskeletal pain 3. ocular inflammation 4. osteonecrosis of the jaw "ALEN + NATE get weird fractures that give you MS pain, inflame your eyes and necrose your jaw"

what is the prototype for estrogen replacement for tx of osteoporosis?

premarin

what is MOA of premarin

suppresses osteoclast proliferation (decreases bone resorption) "pregnant horse pee gives you strong bones"... gross

risks associated with premarin therapy (4)

1. breast CA 2. endometrial CA 3. MI 4. stroke

re: treatment of osteoporosis, what does SERM stand for?

selective estrogen-receptor modifiers

what is the prototype for SERMs?

raloxifene

what is the MOA of raloxifene?

decreases bone resorption (mimics estrogen effects on non-breast cells + / or blocks effects of estrogen on breast cells)

what 3 things does raloxifene improve?

1. bone density 2. lipid profiles 3. CV risk

what are the 3 major risks associated with raloxifene therapy?

1. DVT 2. PE 3. stroke

for tx of osteoporosis, what is the prototype for the monoclonal antibody?

denosumab "den = density"

MOA of denosumab

prevents activation of RANK receptor | RANK receptors are on osteoClasts, so blocking this receptor decreases osteoclast activity

route + frequency of denosumab

SQ q 6 months ◡̈

what should also be taken with denosumab?

vitamin D + Calcium supps

SEs of denosumab (4)

1. injection site rxns 2. pain (back, MS, extremity) 3. UTI 4. hypercholesterolemia

what are the rare/serious AE of denosumab?

1. serious infections 2. derm rxns 3. osteonecrosis of the jaw

what is our prototype drug for increasing bone formation?

teriparatide

MOA of teriparatide

increase bone deposits by osteoblasts = increase bone formation

route for teriparatide

SQ $1500/month! "teri is rich, but we love her b/c shes super generous and gives us all the bone deposits!"

SEs of teriparatide (5)

1. nausea 2. HA 3. back pain 4. leg cramps 5. initial ORTHOSTATIC HYPOTENSION (but generally, well tolerated) *teri's got some period symptoms*

teriparatide therapy is associated with an increased risk of what?

osteosarcoma "teri is so generous and gives gives gives, but sometimes this can be toxic"

what are the 3 classes of antirheumatic drugs?

1. NSAIDS 2. glucocorticoids 3. DMARDs

which of the 3 classes for antirheumatic drugs reduces joint destruction?

DMARDS (disease modifying drugs) *glucocorticoids slow progression of joint damage*

which of the antirheumatic drugs should be started within 3 months of dx of RA?

DMARDs

which of the antirheumatic drugs are really only for symptomatic relief?

NSAIDs

DMARDs are broken up into 2 categories. what are they?

biologic + non-biologic

prototype for non-biologic DMARD agent

methotrexate

how long does methotrexate take to start working? what should be done until they kick in?

3-6 weeks to work NSAID therapy until then

what supplement should be given with methotrexate? what is dosing?

folic acid 5mg/week

how is methotrexate working?

immunosuppressive

SE of methotrexate (7)

1. hepatic fibrosis 2. bone marrow suppression 3. GI ulceration 4. pneumonitis 5. CV disease (reduced life expectancy) 6. *infections* 7. Cancers

what is the prototype for the biologic DMARD?

etanercept

MOA of etanercept

immunosuppressive: targets specific parts of the inflammatory process (mostly tumor necrosis factor)

ALL biologic DMARDs put patient at high risk of what?

INFECTIONS (b/c it's an immunosuppressive)

what should patients be tested for before beginning etanercept therapy?

TB if positive TB test, patient should be treated first!!!

route + frequency for etanercept

SQ twice a week

special considerations for etanercept therapy (4)

1. test for TB + treat if needed 2. watch for Hep B reactivation 3. no active infections 4. no live vaccines

etanercept therapy puts someone at risk for what 4 things?

1. HF 2. cancer 3. CNS disorders 4. serious skin rxns brain, heart, cancer, skin