Pharmacology of Arthritis

Question 1

NSAIDs should generally not be used long term and instead be reserved for _______

Answer 1

Flares

Question 2

NSAIDs have some negative side effects.

List as many as possible

Answer 2

• Peptic ulceration
• Renal impairment
• Increased CV risk
• Exacerbation of asthma
• Fluid retention
• Wheeze
• Rash

Question 3

COX2 inhibitors are a newer form of NSAID which are more effective. However, what is their major downside?

Answer 3

They drastically increase CV risk

Question 4

What is the first line DMARD and when should it ideally be started?

Answer 4

Methotrexate

Within 3 months of symptoms starting

Question 5

How long does it take methotrexate to start working and what can be used for symptoms management in the interim period?

Answer 5

Around 6 weeks

Steroids and anti-inflammatory medication

Question 6

What is the second line treatment for arthritis?

Answer 6

Methotrexate + sulfasalazine

(leflunomide and hydroxychloroquine can also be added if required)

Question 7

How soon must methotrexate be stopped before someone becomes pregnant?

Answer 7

3 months

Question 8

People on methotrexate require frequent blood tests.

What are the main reasons for this?

Answer 8

• Leucopenia
• Thrombocytopenia
• Hepatitis
• Cirrhosis

Question 9

What are some of the negative effects of methotrexate?

Answer 9

• Leucopenia/Thrombocytopenia
• Low sperm count
• Hepatitis
• Cirrhosis
• Nausea/diarrhoea
• Rash
• Mouth ulcers
• Temporary hair loss

Question 10

Leflunomide is a similar drug to methotrexate, but why is it potentially less desirable?

Answer 10

It has a very long half life

Question 11

Sulfasalazine famously can induce which condition?

Answer 11

Stevens-Johnson syndrome

Question 12

What are some of the negative side effects of sulfasalazine?

Answer 12

• Nausea
• Rash
• Mouth ulcers
• Hepatitis
• Reversible low sperm count
• Can induce Stevens-Johnson syndrome

Question 13

Why do patients taking hydroxychloroquine require an annual review?

Answer 13

Hydroxychloroquine can cause irreversible retinopathy

Question 14

Anti-TNF treatment has certain side effects and contraindications. What are these?

Answer 14

Risk of infection - especially reactivation of latent TB

Can increase risk of skin cancer

Contraindicated in heart failure and pulmonary fibrosis

Question 15

Give 2 examples of Anti-TNF drugs

Answer 15

1. Etanercept
2. Adalimumab
3. Certolizumab
4. Infliximab
5. Golimumab

Question 16

Acutely, how is gout treated?

Answer 16

• NSAID e.g. naproxen, ibuprofen
• Colchicine (usually 2nd line anti-inflammatory)
• IM steroid

Question 17

Name two urate lowering drugs used for gout prophylaxis

Answer 17

• Allopurinol
• Febuxostat
• Uricosurics

Question 18

What is a common side effect of allopurinol?

Answer 18

Vasculitic rash

(febuxostat may be better tolerated in such patients)

Question 19

When should urate lowering therapy be administered and why?

Answer 19

2 weeks subsequent to a gout attack

The medication can provoke another gout attack

Question 20

How does allopurinol work?

Answer 20

Inhibits xanthine oxidase

(prevents formation of uric acid)

Question 21

Allopurinol should never be co-prescribed with which other drug and why?

Answer 21

Azathioprine

(It can cause irreversible bone marrow depletion and suppression)

Question 22

When taking urate lowering medication, what is the level to which urate must be lowered to?

Answer 22

< 360mg/l

Question 23

Corticosteroids have many negative side effects.

List as many as possible

Answer 23

• Loss in bone density
• Contribute to diabetes
• Weight gain
• Cattaracts
• Fluid retention
• Avascular necrosis
• Can affect fertility

Question 24

If a young woman is on methotrexate and comes to you for advice about becoming pregnant, what would you tell her?

Answer 24

• Must stop methotrexate for 3 months before attempting to become pregnant
• Must use contraception in these 3 months
• Must switch to sulfasalazine or hydroxychloroquine
• Use steroids in the interim drug change over period
• Once pregnant, inflammatory arthritis commonly improves