Pharmacology of Arthritis Flashcards
What is the first line step in managing pain in arthritis
Non opioid (aspirin, paracetamol, NSAID)
What is the second line step in managing pain in arthritis
Weak opioid (codeine)
What is the third line step in managing persistent pain in arthritis
Strong opioid (morphine)
What are the indications of NSAIDs
Inflammatory arthritis, mechanical MSK pain, pleuritic or pericardial pain
What are the adverse effects of NSAIDs
peptic ulceration, renal impairment, increased Cv risk, exacerbation of asthma, rash, oesophagitis GI symptoms
What does DMARDs stand for
diseae modifying anti rheumatic drugs
Ideally when should DMARD therapy be started in Rheumatoid Arthritis?
Within 3 months of symptoms starting
What describes DMARD therapy
early and aggressive
How fast are DMARDs
slow - weeks to months
How do DMARDs work
pure anti inflammatory with no direct analgesic effect
What do DMARDs reduce the rate of
joint damage
what are commonly used DMARDs
Methotrexate
Sulphasalazine
Leflunomide
Hydroxychloroquine
Is methotrexate safe in pregnancy
NO - must be stopped 3 months before trying to conceive. harms foetus
What are the main DMARDs of choice in Tayside
Methotrexate and sulfasalazine
How can methotrexate be given
orally or by sub cut injection
What is methotrexate used in
RA, psoriatic arthritis, Connective Tissue Disease and Vasculitis
What are the adverse effects of methotrexate
Leucopenia / thrombocytopenia Hepatitis / cirrhosis (alcohol intake must be limited) Pneumonitis Rash / mouth ulcers Nausea / diarrhoea Needs monitoring of FBC and LFTs
What are other DMARDs used in tayside
leflunomide and hydroxychloroquine
What are the adverse effects of sulfasalazine
Nausea Rash / mouth ulcers Neutropenia Hepatitis Reversible low sperm count Monitoring of FBC and LFTs
When is hydroxychloroquine used
in connective tissue disease such as SLE (helps skin, joints and general malaise) Sjogren’s syndrome and RA
what is a rare side effect of HCQ
retinopathy
What do biologic drugs target
specific aspects of immune system found to be implicated in inflammatory arthritis
What is more effective - DMARDs or Biologics
Biologics
When can a biologic be prescribed
after the failure of 2 DMARDs, or in ankylosing spondylitis after the failure of 2 NSAIDs
What is Anti TNF therapy licensed for
RA, psoriatic arthritis and ankylosing spondylitis
How is anti tnf therapy given
majority by sub cut injection
Anti TNF therapy drugs
Etanercept Adalimumab Certolizumab Infliximab Golimumab
What are the adverse effects of anti tnf therapy
Risk of infection (esp TB)
Question over risk of malignancy (esp skin cancer)
Contraindicated in certain situations e.g. pulmonary fibrosis, heart failure
The other biologics…
Rituximab - monoclonal antibody against B (CD20) lymphocytes
Tocilizumab – inhibits interleukin 6
Abatacept - CTLA-4 Ig -blocks full activation of T lymphocytes
Ustekinumab – inhibits IL12 and IL23
Secukinimab – inhibits IL17
Tofacitinib/baricitinib – Janus kinase inhibitors
What are the two components of gout treatment
acute episode treatment and prophylaxis
How is an acute episode of gout treated
NSAIDs, colchicine, steroids
When is allopurinol given
started 4-6 weeks after acute flare, as if started during can make the gout worse!!
What is allopurinol
xanthine oxidase inhibitor - it is a urate lowering drug
What are the adverse effects of allopurinol
rash (vasculitis). azathioprine interaction, rarely bone marrow aplasia
What are other urate lowering drugs
Febuxostat and Uricosurics
What is common side effect of colchichine
diarrhoea
When is febuxostat used
those who cannot tolerate allopurionol - avoid in patients with ischaemic heart disease
What are the indications for corticosteroids
Inflammatory arthritis, Polymyalgia rheumatica / giant cell arteritis, Vasculitis
corticosteroids adverse effects
Weight gain - centripetal obesity Muscle wasting Skin atrophy Osteoporosis Diabetes Hypertension
corticosteroids adverse effects
Cataract Glaucoma Fluid retention Adrenal Suppression Immunosuppression Avascular necrosis of the femoral head
What is the general rule when giving corticosteroids
use lowest possible dose and for shortest time possible
what is methotrexate
a folate antagonist
