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MSK- Rheumatology > Pharmacology of Arthritis > Flashcards

Pharmacology of Arthritis Flashcards

1
Q

What are the two main categories of drugs for arthritis treatment?

A

Symptom relief

Disease modifiers

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2
Q

Name four groups of drugs which can be used for symptom relief?

A
  • Paracetamol
  • Opiates
  • NSAIDs
  • Atypical analgesics
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3
Q

Name two groups of drugs which are disease modifiers?

A
  • DMARDs

- Biologics

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4
Q

What is the role of paracetamol?

A

Pure analgesic (not anti-inflammatory)

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5
Q

Does paracetamol have many side effects?

A

Not really

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6
Q

When does paracetamol become dangerous?

A

When overdosed

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7
Q

Does paracetamol cause renal impairment?

A

No

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8
Q

Is paracetamol safe to use in pregnancy?

A

Yes

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9
Q

What is the first step of pain relief medication? Give examples.

A

Non-opioid: paracetamol, aspirin, NSAID

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10
Q

What is the second step of pain relief medication? Give examples.

A

Weak opioid: codeine +/- non-opioid

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11
Q

What is the third step of pain relief medication? Give examples.

A

Strong opioid: morphine +/- non-opioid

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12
Q

Give two examples of atypical analgesics?

A

Amitriptyline and gabapentin

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13
Q

What type of drug is amitriptyline?

A

Tricyclic anti-depressant

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14
Q

What type of pain is gabapentin good for?

A

Neuropathic pain

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15
Q

What are the actions of NSAIDs?

A

Analgesic and anti-inflammatory

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16
Q

When are NSAIDs used?

A

Relief of acute pain, not much use in the long term

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17
Q

Why are NSAIDs not useful in the long term?

A

Lots of side effects

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18
Q

Give 3 examples of NSAIDs?

A

Ibuprofen, naproxen, diclofenac

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19
Q

Give 5 GI side-effects of NSAIDs?

A
  • Peptic ulcers
  • Dyspepsia
  • Oesophagitis
  • Gastritis
  • Bowel ulcerations
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20
Q

Give 5 non-GI side effects of NSAIDs?

A
  • Fluid retention
  • Exacerbation of asthma
  • Rash
  • Increased CV risk
  • Renal impairment
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21
Q

What kind of drug is celecoxib?

A

COX2 inhibitor, a type of NSAID

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22
Q

What do COX2 inhibitors target?

A

Cyclooxygenase-2, an enzyme responsible for inflammation and pain

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23
Q

What is the major advantage of COX2 inhibitors?

A

They have no risk of peptic ulceration

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24
Q

What is the major disadvantage of COX2 inhibitors?

A

Greatly increase CV risk

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25
Q

Who are COX2 inhibitors given to?

A

People with no other CV risk factors

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26
Q

What is the number 1 treatment for inflammatory arthritis?

A

DMARD therapy- methotrexate

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27
Q

What drug should be co-administered with DMARDs?

A

Steroids

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28
Q

Are the steroids which are given alongside DMARDs continuous?

A

No

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29
Q

What effect do DMARDs have?

A

Halt disease progression, anti-inflammatory

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30
Q

How soon do DMARDs need to be started to achieve full effect?

A

Within the first 3 months

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31
Q

Do DMARDs have any analgesic effects?

A

No

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32
Q

How are patients on DMARDs monitored?

A

Blood tests every 4 weeks, especially FBC and LFTs for low white cell count or liver damage

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33
Q

Once there is joint damage, can it ever be regained?

A

No

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34
Q

What are the indications for using DMARDs?

A

Active inflammatory diseases where the benefits will outweigh the risks

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35
Q

Name 4 DMARDs?

A
  • Methotrexate
  • Sulphasalazine
  • Leflunomide
  • Hydroxychloroquine
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36
Q

What is the mode of action of methotrexate?

A

Folate antagonist- blocks dihydrofolate reductase

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37
Q

What supplements must always be given with methotrexate?

A

Folic acid

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38
Q

How can methotrexate be administered?

A

Oral or subcutaneous injection

39
Q

Give 4 uses of methotrexate?

A
  • RA
  • Psoriatic arthritis
  • CTD
  • Vasculitis
40
Q

What are the major worries with methotrexate, that blood tests are taken to monitor?

A
  • Leukopenia/thrombocytopenia i.e. weakened immune system
  • Myelosuppression (bone marrow suppression)
  • Hepatotoxicity (hepatitis/cirrhosis)
41
Q

What should be limited to help avoid hepatotoxicity when taking methotrexate?

A

Alcohol

42
Q

What lung problems can methotrexate cause? When do these present?

A 
Pneumonitis (fairly soon after starting)
Pulmonary fibrosis (in older patients who have been on the medication for a long time)
43
Q

Patients are told to report if they feel what to help avoid progression of pneumonitis?

A

Dyspnoea or have a cough

44
Q

What are some general side effects of methotrexate?

A

Rash, mouth ulcers, nausea, diarrhoea

45
Q

What is the rule with methotrexate and pregnancy?

A

Teratogenic- must be stopped in both males and females 3 months before conception (and contraception used in that time)

46
Q

What type of drug is sulphasalazine?

A

Aminosalicylate

47
Q

How is sulphasalazine taken?

A

Orally

48
Q

What are the side effects of sulphasalazine?

A
  • Nausea, rash, mouth ulcers
  • Neutropenia and thrombocytopenia
  • Hepatitis
  • Temporary oligozoospermia
  • Stevens-Johnsons Syndrome
  • Severe depression
49
Q

What does leflunomide inhibit?

A

Dihydroorotate dehydrogenase

50
Q

What is the major side effect of leflunomide?

A

Interstitial lung disease

51
Q

Apart from ILD, what are some other side effects of leflunomide?

A
  • Hepatotoxicity
  • Hypertension
  • Alopecia, eczema
  • Pancytopenia
  • GI upset
52
Q

What are the rules with leflunomide and pregnancy?

A

Also teratogenic, with a long half-life so will need a wash out if the patient wants to get pregnant

53
Q

What drug should be used next if methotrexate causes too many side effects?

A

Leflunomide

54
Q

What type of drug is hydroxychloroquine?

A

Anti-malarial

55
Q

When is hydroxychloroquine mainly used?

A

CTD (e.g. SLE)

56
Q

What is the effect of hydroxychloroquine on joint damage?

A

No effect

57
Q

Give 4 side effects of hydroxychloroquine?

A
  • Irreversible retinopathy
  • Corneal deposits
  • Haemolytic anaemia
  • GI upset
58
Q

Give two DMARD drugs which are used rarely now?

A

IM gold

Oral penicillamine

59
Q

Azathioprine is a derivative of what?

A

Mercaptopurine

60
Q

What are some side effects of azathioprine?

A
  • Myelosuppression and neutropenia
  • Hepatotoxicity
  • Pancreatitis
  • GI upset
61
Q

Is azathioprine teratogenic?

A

Yes

62
Q

How do biologics work?

A

Drugs are designed to target specific aspects of the immune system which are implicated in a disease

63
Q

If patients are going to respond to biologics, how will this occur?

A

Very quickly with a vast improvement

64
Q

How are most biologics given?

A

Subcutaneous injection every 1-2 weeks

65
Q

Give 2 examples of anti-TNFs which are given subcutaneously?

A
  • Adalimumab

- Etanercept

66
Q

What is a side effect of etanercept?

A

Demyelination

67
Q

What is an example of an anti-TNF given IV?

A

Infliximab

68
Q

What is TNF?

A

A cytokine which is a driving force in inflammation

69
Q

Who are given biologics?

A

Those with a DAS28 score of > 5.1 and have been on at least two DMARDs including methotrexate

70
Q

What is the major risk of biologics?

A

Immunosuppression

71
Q

What must all patients be screened for before starting biologics? Why?

A

TB- biologics can cause reactivation of latent TB

72
Q

Biologics cause increased risk of which cancer?

A

Melanoma

73
Q

What cardiac effect do biologics have?

A

Worsen heart failure

74
Q

Are biologics teratogenic?

A

No

75
Q

What is rituximab and when is it used?

A

A monoclonal antibody against B cells so can be used in any condition where autoantibodies are present

76
Q

What does tocilizumab do?

A

Inhibit IL-6

77
Q

What does abatacept do?

A

Blocks full activation of T cells so they cannot interact with B cells

78
Q

What does ustekinumab do?

A

Inhibit IL-12 and IL-23

79
Q

What does secukinamb do?

A

Inhibit IL-17

80
Q

IL-12, IL-23 and IL-17 blockers are useful in what condition? Why?

A

Psoriatic arthritis as this is T cell driven

81
Q

What does ciclosporin do?

A

Blocks cytotoxic T cell activation

82
Q

What are some side effects of ciclosporin?

A
  • Immune suppression
  • Nephrotoxicity
  • Hepatotoxicity
  • Hypertension
  • GI upset
83
Q

What is a side effect of colchicine?

A

Diarrhoea

84
Q

What do steroids do to bones?

A

Loss of bone density so can give osteoporosis

85
Q

What supplements should be given when takin steroids?

A

Calcium and vitamin D

86
Q

How do steroids contribute to the development of diabetes?

A

Cause weight gain due to increased appetite and fluid retention

87
Q

What drug should be used for gout prophylaxis in patients with kidney disease?

A

Febuxostat

88
Q

When should you use febuxostat with caution?

A

Ischaemic heart disease

89
Q

What is a side effect of allopurinol?

A

Vasculitis like rash

90
Q

Who should be given lower doses of allopurinol?

A

Elderly and renal impaired (more likely to get the rash)

91
Q

What happens on interaction of allopurinol and azathioprine?

A

Irreversible bone marrow suppression

92
Q

You can prescribe allopurinol up to doses of what?

A

900mg

93
Q

Patients on methotrexate who want to conceive can be switched to which drugs?

A
  • Sulphasalazine

- Biologics (if they meet the requirements)

94
Q

What happens to RA in pregnancy?

A

It often gets better but then dips again after birth

MSK- Rheumatology (12 decks)

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