Pharmacology in Arthritis Flashcards by Gillian Miller

Disease modifying drugs in arthritis

DMARDS, Biologics

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DMARDS used in Arthritis?

Methotrexate
Sulfasalazine
Hydroxychloroquine

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Biologics used in arthritis?

Anti-TNF
Rituximab
Tocilizumab

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Name a pure analgesic

Paracetemol

anti-pyretic, little anti-inflamm effect

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Analgesics

Co-codamol
Dihydrocodeine
Tramadol
Amitryptiline
Gabapentin

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Properties of NSAIDS

Anti-inflammatory
Analgesic
Antipyretic
Antiplatelet

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Adverse effects of NSAIDS?

Ulceration, oesophagitis, gastritis etc
Renal impairment
Increased cardiovascular events (Cox 2 inhibitors + others)
Fluid retention
Wheeze
Rash

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Are DMARDS slow acting?

Yes (weeks - months)

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Do DMARDS have any analgesic effect?

No! Purely anti-inflammatory
Improve standard laboratory tests of inflammation e.g.ESR, CRP
Reduce rate of joint damage

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What kind of drug might improve standard laboratory tests of inflammation (e.g. ESR and CRP)

DMARDS

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How quickly do you want to try and get someone with arthritis onto DMARDS?

Within 3 months of symptoms

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Vaccines and DMARDS?

Vaccines should be given before DMARDS are started

-Live vaccines should not be given

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DMARDS of choice?

Sulfasalazine, methotrexate
(remember DMARD combination therapy!! both together!!)
Make it intensive!

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Methotrexate is an antagonist of what?

Folate

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How can methotrexate be given?

Orally or subcutaneously

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What is thrombocytopenia?

Deficiency of platelets, this can cause bleeding into tissues, bruising and slow blood clotting after injury

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Adverse effects of methotrexate

TERATEGENIC (STOP 3MONTHS BEFORE 
Myelotoxicity, fibrosing alveolitis
Leucopenia / thrombocytopenia 
Hepatitis / cirrhosis (alcohol intake must be limited)
Pneumonitis
Rash / mouth ulcers
Nausea / diarrhoea
Needs monitoring of FBC and LFTs

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Why should alcohol intake be limited when on methotrexate?

Methotrexate can cause cirrhosis/hepatitis

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Why do you need to monitor LFTS and FBC when you’re on methotrexate?

Methotrexate can cause cirrhosis/hepatitis, leucopania and thrombocytopenia (and others)

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What is sulfasalazine?

An azo ester of sulfapyridine and 5-aminosalicylic acid

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Which DMARD can cause neutropenia?

Sulfasalazine

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Which DMARD can cause reversible oligozoospermia?

Sulfasalazine

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Effects of Hydroxycloroquine

No effect on joint damage

Used in connective tissue diseases such as SLE (helps skin, joints and general malaise), Sjogrens and RA

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Rare adverse effect of hydroxychloroquine?

Retinopathy

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Name a DMARD which can help in SLE and its effects

Hydroxychloroquine (helps skin, joints and general malaise)

Side effects of sulfasalazine?

``` Oligospermia Myelotoxicty, hepatotoxicity, hypersensitivity reactions Nausea Neutropania Hepatitis Rash/Mouth Ulcers ```

Anti-TNF that can be given intravenously?

Infliximab

Subcutaneous Anti-TNF therapies?

Etanercept Adalimumab Certolizumab Golimumab

What can anti-TNF therapy be used in?

Rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis

Contra-indications to anti-TNF therapy?

Pulmonary fibrosis, heart failure

Co-codamol?

Analgesic

Dihydrocodeine?

Analgesic

Tramadol?

Analgesic

Amitryptiline?

Analgesic

Gabapentin?

Analgesic

Folate antagonist

Methotrexate

How is methotrexate administered?

Methotrexate can be administers orally or subcutaneously

What is methotrexate used in?

RA, psoriatic arthritis, connective tissue disease and vasculitis

Methotrexate side effects

``` Myelotoxicity, fibrosing alveolitis TERATOGENIC Leucopenia / thrombocytopenia Hepatitis / cirrhosis (alcohol intake must be limited) Pneumonitis Rash / mouth ulcers Nausea / diarrhoea Needs monitoring of FBC and LFTs ```

Side effects of sulfasalazine?

``` Nausea Rash, mouth ulcers Hepatitis Neutropenia Oligozoospermia ```

Side effect of anti-malarial drugs?

Retinopathy

Side effect of ciclosporin?

Nephrotoxicity, hypertension

Can NSAIDS cause renal impairment?

yesh

NSAID adverse effects

- gastric ulcers - oesophagitis - bowel ulceration - dysphagia - gastritis - Renal impairment - Increased cardiovascular events (Cox 2 inhibitors + others) - Fluid retention - Wheeze - Rash

How do you make anti-TNF therapy more effective?

Give in combination with DMARDS

When is anti-TNF contraindicated?

Pulmonary fibrosis, heart failure

Ustekinumab?

IL12 and IL13 inhibitor

CTLA-4 Ig (blocks full activation of T cells)

Abatecept

What does abatacept do?

Blocks full activation of T cells | CTLA-4

Inhibits interleukin 6?

Tocilizumab

Monoclonal antibody against CD20?

Rituximab

Side effects of colchicine?

Diarrhoea and vomitting

Urate lowering drugs

Allopurinol Febuxostat Uricosurics

What do allopurinol and febuxostat do?

Stop the conversion of xanthine to uric acid | allopurinol is a xanthine oxidase inhibitor

Name a xanthine oxidase inhibitor?

Allopurinol

Why do you not prescribe allopurinol initially for acute attacks?

Rapid reductio in uric acid could result in exacerbation of gout. Always co-prescribe anti-inflammatory for the first couple of weeks

Which drug may inhibit warfarin metabolism?

Allopurinol

Which drug could cause marrow aplasia?

Allopurinol

Side effects of allopurinol?

Rash (commoner in elderly) AZATHIOPRINE INTERACTION May inhibit warfarin metabolism Rarely, marrow aplasia

Which drug can allopurinol react with?

Azathioprine

When would you give febuxostat?

For someone who can't tolerate allopurinol

Which drug can you give if someone can't tolerate allopurinol?

Febuxostat

When is the rash from allopurinol more common?

In old people and people with renal impairment

Uricosurics

Probenecid Sulphinpyrazone Azapropazone Benzbromarone

Metabolic effects of corticosteroids?

Salt and water retention Increased gluconeogenesis Increased hepatic glycogen deposition Increased protein breakdown

Effects of corticosteroids on the eyes?

Glaucoma, cataratcs

Side effects of leflunomide

Leflunomide (DMARD) | -nausea, diarrhoea and mouth ulcers

Corticosteroids and adrenal suppression?

Corticosteroids can cause adrenal suppression

PTH

Squamous cell carcinoma

ACTH

Small cell

P63

Squamous cell

TTF-1

Small cell and adeoncarcinoma

Cavitates, central necrosis | Keratin

Squmaous cell carcinoma

Biologics for ankylosing spondylitis

IA Infliximab Adalimumab

Biologics for SLE

Rituximab | Belimumab

Biologics for psoriatic arthritis

Etanercept | Ustekinab

When is anti-TNF contraindicated?

Pulmonary fibrosis | Heart failure