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MSK > Pharmacology of Arthritis > Flashcards

Pharmacology of Arthritis Flashcards

1
Q

what is the 3 steps of the pain ladder

A

non-opiod (aspirin, paracetamol or NSAID) +/- adjuvant

weak opioid for mild to moderate pain (e.g. codeine) +/- non opioid +/- adjuvant

strong opiod for moderate to severe pain (e.g. morphine) +/- non-opioid +/- adjuvant

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2
Q

what are examples of adjuvant therapies in the pain ladder

A

muscle relaxants, anticonvulsants, antipsychotics, antidepressants, corticosteroids, anxiolytics and psychostimulants

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3
Q

what is the actions of NSAIDs

A

non steroidal anti-inflammatory

analgesic

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4
Q

name 4 NSAIDs

A

ibuprofen, naproxen, diclofenac, celecoxib (cox 2 inhibitor)

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5
Q

what are the indicators for NSAIDs

A

inflammatory arthritis, mechanical MSK pain, pleuritic/ pericardial pain (CTD)

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6
Q

what are the adverse affects of NSAIDs

A 
dyspepsia, 
oesophagus, 
gastritis, 
peptic ulcer, 
small/large bowel ulceration,
renal impairment,
increased cardiovascular events (cox 2 inhibitors + all anti-inflammatory),
fluid retention,
wheeze,
rash
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7
Q

what does DMARD stand for

A

disease modifying anti-rheumatic drug

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8
Q

what is the treatment for inflammatory arthritis

A

early, aggressive DMARD therapy within three months of symptom onset

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9
Q

what do DMARDs do

A

pure anti inflammatory with no analgesic effect

reduce rate of joint damage and inflammatory markers

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10
Q

what are the DMARDs of choice

A

methotrexate and sulfasalazine

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11
Q

name two other DMARDs

A

leflunomide

hydroxychloroquine

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12
Q

how long do DMARDS take to work

A

6 weeks- can use steroids as a bridge to reduce inflammation

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13
Q

how does methotrexate work

A

folate antagonist

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14
Q

how can methotrexate be administered

A

orally or subcutaneously

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15
Q

what is methotrexate used in

A

RA, psoriatic arthritis, CTD and vasculitis

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16
Q

can you gain normal joint function after the window of oppurtunity

A

no

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17
Q

what are the adverse effects of methotrexate

A 
leucopenia/ thrombocytopenia 
hepatitis, cirrhosis (alcohol intake must be limited)
pneumonitis 
rash, mouth ulcers
nausea, diarrhoea
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18
Q

what do you need to monitor in methotrexate

A

FBC and LFTs

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19
Q

is methotrexate safe in pregnancy

A

no is teratogenic- must be stopped in males and females at least 3 months before conception

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20
Q

describe leflunomide

A

DMARD
similar efficacy and side effects to methotrexate
also teratogenic

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21
Q

what is an additional requirement of leflunomide

A

requires a wash out due to its very long half life

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22
Q

when and with what is sulfasalazine used

A

often used in early inflammatory arthritis in combo with methotrexate

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23
Q

what are the adverse effects of sulfasalazine

A 
nausea
rash/mouth ulcers
neutropenia
hepatitis 
reversible oligozoospermia (reduced sperm count)
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24
Q

what do you need to monitor in sulfasalazine

A

FBC and LFT

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25
Q

does hydroxychloroquine affect joint damage

A

no effect on joint damage

26
Q

when is hydroxychloroquine used

A

CTD: SLE, sjogrens and RA

27
Q

what do biologics do

A

target specific aspects of the immune system found to be implicated in inflammatory arthritis

28
Q

what do biologics target

A

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

29
Q

what is anti TNF used for

A

RA, psoriatic arthritis, ankylosing spondylitis

30
Q

is sulfasalazine safe in pregnancy

A

yes- when also taking folic acid supplement

31
Q

can anti TNF be used in combo with DMARDs

A

yes- makes it more effective

32
Q

is anti TNF safe in pregnancy and breast feeding

A

yes

33
Q

give examples of anti TNF drugs

A

etanercept, the ‘-mab’s’

34
Q

how are most anti tnfs delivered

A

sub cutaneously

35
Q

why is TNF targeted

A

as is an intergral cytokine in sad conditions (RA, psoriatic arthritis, AS)

36
Q

what is the criteria for anti TNF use

A

high disease activity score

use of previous standard DMARDs

37
Q

what are the adverse effects of anti TNF

A

risk of infection (especially TB), possible risk of malignancy

contraindicated in certain situations (pulmonary fibrosis, heart failure)

38
Q

what does rituximab target

A

monoclonal antibody against B (CD20) lymphocytes

39
Q

what does tocilizumab do

A

inhibits IL-6

40
Q

what does abatacept do

A

CTLA-4 Ig- blocks full activation of T lymphocytes

41
Q

what does ustekinumab do

A

inhibits IL 12 and 23

42
Q

what does secukinimab do

A

inhibtis IL 17

43
Q

what does tofacitinib/ baricitinib do

A

janus kinase inhibitors

44
Q

what is used to treat an acute episode of gout

A

colchicine (diarrhoea common)
NSAIDs (naproxen)
steroids (either oral/IM)

45
Q

what is used as gout prophykaxis- how does it work

A

urate lowering drugs:

allopurinol (increased gradually whilst checkin urate levels)
febuxostat
uricosurics

46
Q

what is the threshold for urate

A

360 micromoles

47
Q

in an acute episode of gout would you stop previously prescribes allopurinol

A

no

48
Q

what is allopurinol

A

xanthine oxidase inhibitor

49
Q

is febuxostat safe to give patients who have renal failure

A

yes

50
Q

what are the adverse effects of allopurinol

A

rash (vasculitis- commonly in elderly and in renal impairment- use lower doses)

azathioprine interaction

rarely marrow aplasia

51
Q

how does febuxostat work

A

xanthine oxase inhibitor

52
Q

when would you give febuxostat instead of allopurinol

A

if patients cannot tolerate allopurinol (e.g. renal impairment)

53
Q

what should you be cautious of in febucostat

A

if patients have ischaemic heart disease

54
Q

name some uricosurics

A

probenecid
sulphinpyrazone
azapropazone
benzbromarone

55
Q

what rheumatological problems are corticosteroids used in

A

CTD, polymyalgia rheumatica/giant cell arteritis, vasculitis, RA

56
Q

how can you administer corticosteroids

A

oral, IA, soft tissue injections, IM, IV

57
Q

what are the adverse effects of corticosteroids

A 
weight gain (centripetal obesity)
muscle wasting 
skin atrophy 
osteoporosis 
diabetes 
hypertension
cataracts 
glaucoma
fluid retention 
adrenal suppression 
immunosuppression
avascular necrosis of the femoral head
58
Q

how do you reduce the toxicity of corticosteroids

A

lowest dose for shortest time possible
steroid sparing agents
osteoporosis prophylaxis
watch cardio risk factors

59
Q

what usually happens to RA in pregnancy

A

gets better

60
Q

how often do you take nwthotrexate

A

weekly

MSK (71 decks)

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