Pharmacology of Arthritis

Question 1

what is the 3 steps of the pain ladder

Answer 1

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

Question 2

what are examples of adjuvant therapies in the pain ladder

Answer 2

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

Question 3

what is the actions of NSAIDs

Answer 3

non steroidal anti-inflammatory

analgesic

Question 4

name 4 NSAIDs

Answer 4

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

Question 5

what are the indicators for NSAIDs

Answer 5

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

Question 6

what are the adverse affects of NSAIDs

Answer 6

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

Question 7

what does DMARD stand for

Answer 7

disease modifying anti-rheumatic drug

Question 8

what is the treatment for inflammatory arthritis

Answer 8

early, aggressive DMARD therapy within three months of symptom onset

Question 9

what do DMARDs do

Answer 9

pure anti inflammatory with no analgesic effect

reduce rate of joint damage and inflammatory markers

Question 10

what are the DMARDs of choice

Answer 10

methotrexate and sulfasalazine

Question 11

name two other DMARDs

Answer 11

leflunomide

hydroxychloroquine

Question 12

how long do DMARDS take to work

Answer 12

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

Question 13

how does methotrexate work

Answer 13

folate antagonist

Question 14

how can methotrexate be administered

Answer 14

orally or subcutaneously

Question 15

what is methotrexate used in

Answer 15

RA, psoriatic arthritis, CTD and vasculitis

Question 16

can you gain normal joint function after the window of oppurtunity

Answer 16

no

Question 17

what are the adverse effects of methotrexate

Answer 17

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

Question 18

what do you need to monitor in methotrexate

Answer 18

FBC and LFTs

Question 19

is methotrexate safe in pregnancy

Answer 19

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

Question 20

describe leflunomide

Answer 20

DMARD
similar efficacy and side effects to methotrexate
also teratogenic

Question 21

what is an additional requirement of leflunomide

Answer 21

requires a wash out due to its very long half life

Question 22

when and with what is sulfasalazine used

Answer 22

often used in early inflammatory arthritis in combo with methotrexate

Question 23

what are the adverse effects of sulfasalazine

Answer 23

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

Question 24

what do you need to monitor in sulfasalazine

Answer 24

FBC and LFT

Question 25

does hydroxychloroquine affect joint damage

Answer 25

no effect on joint damage

Question 26

when is hydroxychloroquine used

Answer 26

CTD: SLE, sjogrens and RA

Question 27

what do biologics do

Answer 27

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

Question 28

what do biologics target

Answer 28

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

Question 29

what is anti TNF used for

Answer 29

RA, psoriatic arthritis, ankylosing spondylitis

Question 30

is sulfasalazine safe in pregnancy

Answer 30

yes- when also taking folic acid supplement

Question 31

can anti TNF be used in combo with DMARDs

Answer 31

yes- makes it more effective

Question 32

is anti TNF safe in pregnancy and breast feeding

Answer 32

yes

Question 33

give examples of anti TNF drugs

Answer 33

etanercept, the '-mab's'

Question 34

how are most anti tnfs delivered

Answer 34

sub cutaneously

Question 35

why is TNF targeted

Answer 35

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

Question 36

what is the criteria for anti TNF use

Answer 36

high disease activity score | use of previous standard DMARDs

Question 37

what are the adverse effects of anti TNF

Answer 37

risk of infection (especially TB), possible risk of malignancy contraindicated in certain situations (pulmonary fibrosis, heart failure)

Question 38

what does rituximab target

Answer 38

monoclonal antibody against B (CD20) lymphocytes

Question 39

what does tocilizumab do

Answer 39

inhibits IL-6

Question 40

what does abatacept do

Answer 40

CTLA-4 Ig- blocks full activation of T lymphocytes

Question 41

what does ustekinumab do

Answer 41

inhibits IL 12 and 23

Question 42

what does secukinimab do

Answer 42

inhibtis IL 17

Question 43

what does tofacitinib/ baricitinib do

Answer 43

janus kinase inhibitors

Question 44

what is used to treat an acute episode of gout

Answer 44

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

Question 45

what is used as gout prophykaxis- how does it work

Answer 45

urate lowering drugs: allopurinol (increased gradually whilst checkin urate levels) febuxostat uricosurics

Question 46

what is the threshold for urate

Answer 46

360 micromoles

Question 47

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

Answer 47

no

Question 48

what is allopurinol

Answer 48

xanthine oxidase inhibitor

Question 49

is febuxostat safe to give patients who have renal failure

Answer 49

yes

Question 50

what are the adverse effects of allopurinol

Answer 50

rash (vasculitis- commonly in elderly and in renal impairment- use lower doses) azathioprine interaction rarely marrow aplasia

Question 51

how does febuxostat work

Answer 51

xanthine oxase inhibitor

Question 52

when would you give febuxostat instead of allopurinol

Answer 52

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

Question 53

what should you be cautious of in febucostat

Answer 53

if patients have ischaemic heart disease

Question 54

name some uricosurics

Answer 54

probenecid sulphinpyrazone azapropazone benzbromarone

Question 55

what rheumatological problems are corticosteroids used in

Answer 55

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

Question 56

how can you administer corticosteroids

Answer 56

oral, IA, soft tissue injections, IM, IV

Question 57

what are the adverse effects of corticosteroids

Answer 57

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

Question 58

how do you reduce the toxicity of corticosteroids

Answer 58

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

Question 59

what usually happens to RA in pregnancy

Answer 59

gets better

Question 60

how often do you take nwthotrexate

Answer 60

weekly