Pharmacology of Arthritis

Question 1

what is the ladder of pain management (WHO)?

Answer 1

non-opioids +/- adjuvant
weak opioid for mild-moderate pain +/- non opioid +/- adjuvant
strong opioid (morphine) +/- non-opioids +/- adjuvant

Question 2

indications for NSAIDs?

Answer 2

inflammatory arthriitis
mechanical MSK pain
pleuritic/pericardial pain (connective tissue disease)

Question 3

NSAIDs side effects?

Answer 3

peptic ulceration
renal impairment
increased cardio risk (if taken regularly over long time)
exacerbation of asthma

Question 4

first line for newly diagnosed rheumatoid arthritis?

Answer 4

methotrexate (first line DMARD)

also use steroids in the short term to help symptoms

Question 5

when should methotrexate be started?

Answer 5

within 3 months of symptom onset

Question 6

next step if RA doesn’t responds to standard DMARD therapy?

Answer 6

biological agents

Question 7

how do DMARDs work?

Answer 7

slow acting
only anti inflammatory - no analgesic effect
improve standard ab tests (CRP?ESR)
reduce rate of joint damage

Question 8

does DMARD therapy need to be monitored?

Answer 8

yes

Question 9

do DMARDs improve pain?

Answer 9

no

Question 10

best treatment method for RA treatment?

Answer 10

early intervention (first 3 months)
aggressive treatment

Question 11

common DMARDs?

Answer 11

methotrexate
sulfasalazine
leflunomide
hydroxychloroquine

Question 12

what is a risk of methotrexate?

Answer 12

can cause problems in pregnancy

must stop taking it before 3 months before trying to concieve

Question 13

how can methotrexate be administered?

Answer 13

oral

IV

Question 14

what is methotrexate?

Answer 14

folate antagonist

Question 15

methotrexate side effects?

Answer 15

pneumonitis
low WCC
thrombocytopenia
hepatitis/cirrhosis
rash/mouth ulcers
nausea

Question 16

which drug is similar to methotrexate?

Answer 16

lelflunamide has similar effectiveness and side effects

Question 17

problem with leflunamide?

Answer 17

long half life so has to be washed out

Question 18

sulfasalazine side effects?

Answer 18

nausea
rash/mouth ulcers
neutropenia
hepatitis
reversible oligozoospermia (reduced sperm count)

Question 19

is leflunamide safe in pregnancy?

Answer 19

yes

Question 20

what does hydroxychloroquine do?

Answer 20

doesn’t have an affect on joint damage

used more in connective tissue disease - lupus

Question 21

targets of biological agents?

Answer 21

TNF
CD 20 B cells
interleukin 6
interleukin 17, 12 and 23

Question 22

do biologics work for everyone?

Answer 22

no

but generally more effective than DMARDs

Question 23

do biological agents have side effects?

Answer 23

yes

Question 24

what is anti TNF used for?

Answer 24

RA
psoriatic arthritis
ankylosing spondylitis

Question 25

how is anti TNF given?

Answer 25

sub cutaneous injection

Question 26

examples if anti TNF?

Answer 26

etanercept
infliximab
adalinumab

Question 27

criteria for anti TNF use?

Answer 27

DAS28 >5.1

use of previous standard DMARDs

Question 28

side effects of anti TNF?

Answer 28

re-activation of latent TB
increased infection risk
increases skin cancer risk (only slightly)
exacerbate heart failure (contraindicated if patient has severe heart failure)

Question 29

does anti TNF cause foetal abnormalities?

Answer 29

no

therefore safe n pregnancy

Question 30

does inflammatory/rheumatoid arthritis improve or worsen in pregnancy?

Answer 30

improve generally

Question 31

what are the 2 components of gout treatment?

Answer 31

treat acute flare

gout attack prophylaxis

Question 32

what is not used during a flare of gout?

Answer 32

allopurinol

Question 33

if someone is already on allopurinol and has a flare, do you stop it?

Answer 33

no

Question 34

other gout medications

Answer 34

naproxen
colchicine
prednisolone
intramuscular steroid

Question 35

treatment for actute episode of gout?

Answer 35

colchicine
NSAIDs
steroids

Question 36

gout prophylaxis?

Answer 36

lower urate

• allopurinol (first line)
• febuxostat (used if theres renal failure?)
• uricosurics

Question 37

what is allopurinol side effcts?

Answer 37

rash (vasculitis) - common in elderly and if theres renal failure
azathioprine interaction - can suppress bone marrow
rarely causes marrow aplasia

Question 38

what is used if allopurinol not tolerated (e.g renal failure)?

Answer 38

febuxostat

Question 39

goal for urate?

Answer 39

<360 micro moles per litre

- always monitor during treatment

Question 40

how long should steroids be used?

Answer 40

as short a time as possible

Question 41

side effects of steroids?

Answer 41

loss of bone density (osteoporosis risk)
can contribute to diabetes development
can cause weight gain (mainly oral if over long time)
muscle wasting
skin atrophy

Question 42

how can steroid risk be reduced?

Answer 42

use for short time
use lowest dose possible
consider steroid sparing agents
prophylaxis for osteoporosis

Question 43

possible cause of cough and breathlessness with bilateral crackles 12 weeks after starting methotrexate?

Answer 43

methotrexate pneumonitis

• due to quick onset
• could have been pulmonary fibrosis if over years of treatment

Question 44

what other DMARD could you use instead of methotrexate if trying to conceive?

Answer 44

sulfasalazine

- must be off methotrexate for 3 months before conceiving