Pharmacology of Arthritis Flashcards
what is the ladder of pain management
- non-opioid (aspirin, paracetamol) +/- adjuvant
2. weak opiod for mild-moderate pain (+/- non opioid +/– adjuvant)
Indications for NSAID use
inflammatory arthritis
mechanical msk pain
pleuritic/pericardial pain
Do NSAIDS help cure inflammatory arthritis
No
just dampen down inflammation
side effects of NSAIDS
peptic ulceration
renal impairment
increased cardiovascular risk (if taken regularly over long period of time)
exacerbation of asthma
What is the best treatment choice for newly diagnosed rheumatoid arthritis
Methotrexate!!!!!! (first line DMARD)
Start on steroids at the same time to target inflammation
when should methotrexate be started
within 3 months of symptoms starting
what are biologic drugs
next step on for patients who dont respond to standard DMARD therapy
Limitations with DMARDS
slow acting - weeks to months
no pain relief- purely anti-inflammatory
when is the window of opportunity of intervention for inflammatory arthritis
EARLY to prevent loss of function, if u wait to long normal joint function can never be regained
some common DMARDS
methotrexate
sulfazalazine
leflunomide
hydroxychloroquine
when cant u use methotrexate
IN PREGNANCY
how is methotrexate given
oral or injection
methotrexate side effects
nausea pneumonitis leucopenia/thrombocytopenia hepatitis most ulcers/rasah
therefore needs to be monitored regularly
what is leflunomide
similar to methotrexate
main difference is long held life so required wash out
also tetragenic and needs washed out so avoided in women of child baring age
what are sulfasalazine adverts effects
nausea RASH neuropenia hepatitis reduced sperm count (reversible)
what does hydroxychoroquine do
no effect on joint damage
used more in connective tissue disease
what are biologic drugs
drugs designed to target specific aspects of the immune system found to be implicated in inflammatory arthritis
often first tine
targets for biologics
TNF
IL6
IL 17, 12 and 23
CD 20 B cells
what are more effective, DMARDS or biologics
biologics
only given to those who qualify, v expensive
What is Anti- TNF
biologic
v expensive
for RA, psoriatic arthritis and ankylosing spondylitis
how is anti-TNF given
subcutaneous injection
what does anti-TNF do
targets TNF which is a key cytokine in inflammation
who qualifies for anti-TNF
those with high disease activity
a high DAS28 score
use of 2 DMARDS which they’ve not responded to
what are some side effects of anti-TNF
increased infection risk
increased skin cancer risk
reactivation of latent TB
exacerbation of heart failure
what naturally happens to inflammatory arthritis in pregnancy
it gets better
what is the treatment for gout
1.
2.
what do u give AFTER gout flare has settled
1st line: allopurinol - needs to be increased gradually
febuxostat - works the same way as allopurinol but safe in patients with renal failure
uricosurics
what do u use to treat an acute flare of gout
NSAIDS
steroids - doesn’t matter how given
Colchicine
complications of allopurinol
allergic type rash (commoner in elderly and in renal impairment)
azathioprine interaction - causes irreversible bone marrow suppression
can u co-prescribe azathioprine and allopurinol
NO causes irreversible bone marrow suppression
what is the level of ureate in the blood aimed for after gout treatment
360micomoles/litre
means they will have no more symptoms
indication for steroid use
suppress inflammation quickly in:
connective tissue disease
RA
others..
side effects of steroids
loss of bone density
contribute to development of diabetes
make u fat (oral steroids over prolonged period)
should be used for as short a time as possible
what kind of weight game do steroids give
puffy face
abdominal weight gain
muscle wasting
how do u reduce the risk of steroids
use for as short a time as possible when there is no other option
consider other therapy
monitor cardiac risk factors
possible cause of acute cough and breathlessness in a patient on methotrexate for RA
methotrexate pneumonitis
what should you give a patient who isn’t responding to DMARDS and is in a high disease activity category for RA
start on anti-TNF
if they have latent TB, treat the TB then continue anti-TNF
how long should you wait after stoping methotrexate to finish contraception and get pregnant
3 months
what drug should you give instead of methotrexate when a woman wants to get pregnant
sulphasalazine
how often is methotrexate given
weekly
what DAS28 is ‘high activity’
> 5.1 on DAS28
