Pharmacology of Arthritis

Question 1

What is the first line step in managing pain in arthritis

Answer 1

Non opioid (aspirin, paracetamol, NSAID)

Question 2

What is the second line step in managing pain in arthritis

Answer 2

Weak opioid (codeine)

Question 3

What is the third line step in managing persistent pain in arthritis

Answer 3

Strong opioid (morphine)

Question 4

What are the indications of NSAIDs

Answer 4

Inflammatory arthritis, mechanical MSK pain, pleuritic or pericardial pain

Question 5

What are the adverse effects of NSAIDs

Answer 5

peptic ulceration, renal impairment, increased Cv risk, exacerbation of asthma, rash, oesophagitis GI symptoms

Question 6

What does DMARDs stand for

Answer 6

diseae modifying anti rheumatic drugs

Question 7

Ideally when should DMARD therapy be started in Rheumatoid Arthritis?

Answer 7

Within 3 months of symptoms starting

Question 8

What describes DMARD therapy

Answer 8

early and aggressive

Question 9

How fast are DMARDs

Answer 9

slow - weeks to months

Question 10

How do DMARDs work

Answer 10

pure anti inflammatory with no direct analgesic effect

Question 11

What do DMARDs reduce the rate of

Answer 11

joint damage

Question 12

what are commonly used DMARDs

Answer 12

Methotrexate
Sulphasalazine
Leflunomide
Hydroxychloroquine

Question 13

Is methotrexate safe in pregnancy

Answer 13

NO - must be stopped 3 months before trying to conceive. harms foetus

Question 14

What are the main DMARDs of choice in Tayside

Answer 14

Methotrexate and sulfasalazine

Question 15

How can methotrexate be given

Answer 15

orally or by sub cut injection

Question 16

What is methotrexate used in

Answer 16

RA, psoriatic arthritis, Connective Tissue Disease and Vasculitis

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
Needs monitoring of FBC and LFTs

Question 18

What are other DMARDs used in tayside

Answer 18

leflunomide and hydroxychloroquine

Question 19

What are the adverse effects of sulfasalazine

Answer 19

Nausea
Rash / mouth ulcers
Neutropenia
Hepatitis
Reversible low sperm count
Monitoring of FBC and LFTs

Question 20

When is hydroxychloroquine used

Answer 20

in connective tissue disease such as SLE (helps skin, joints and general malaise) Sjogren’s syndrome and RA

Question 21

what is a rare side effect of HCQ

Answer 21

retinopathy

Question 22

What do biologic drugs target

Answer 22

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

Question 23

What is more effective - DMARDs or Biologics

Answer 23

Biologics

Question 24

When can a biologic be prescribed

Answer 24

after the failure of 2 DMARDs, or in ankylosing spondylitis after the failure of 2 NSAIDs

Question 25

What is Anti TNF therapy licensed for

Answer 25

RA, psoriatic arthritis and ankylosing spondylitis

Question 26

How is anti tnf therapy given

Answer 26

majority by sub cut injection

Question 27

Anti TNF therapy drugs

Answer 27

``` Etanercept Adalimumab Certolizumab Infliximab Golimumab ```

Question 28

What are the adverse effects of anti tnf therapy

Answer 28

Risk of infection (esp TB) Question over risk of malignancy (esp skin cancer) Contraindicated in certain situations e.g. pulmonary fibrosis, heart failure

Question 29

The other biologics...

Answer 29

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

Question 30

What are the two components of gout treatment

Answer 30

acute episode treatment and prophylaxis

Question 31

How is an acute episode of gout treated

Answer 31

NSAIDs, colchicine, steroids

Question 32

When is allopurinol given

Answer 32

started 4-6 weeks after acute flare, as if started during can make the gout worse!!

Question 33

What is allopurinol

Answer 33

xanthine oxidase inhibitor - it is a urate lowering drug

Question 34

What are the adverse effects of allopurinol

Answer 34

rash (vasculitis). azathioprine interaction, rarely bone marrow aplasia

Question 35

What are other urate lowering drugs

Answer 35

Febuxostat and Uricosurics

Question 36

What is common side effect of colchichine

Answer 36

diarrhoea

Question 37

When is febuxostat used

Answer 37

those who cannot tolerate allopurionol - avoid in patients with ischaemic heart disease

Question 38

What are the indications for corticosteroids

Answer 38

Inflammatory arthritis, Polymyalgia rheumatica / giant cell arteritis, Vasculitis

Question 39

corticosteroids adverse effects

Answer 39

``` Weight gain - centripetal obesity Muscle wasting Skin atrophy Osteoporosis Diabetes Hypertension ```

Question 40

corticosteroids adverse effects

Answer 40

``` Cataract Glaucoma Fluid retention Adrenal Suppression Immunosuppression Avascular necrosis of the femoral head ```

Question 41

What is the general rule when giving corticosteroids

Answer 41

use lowest possible dose and for shortest time possible

Question 42

what is methotrexate

Answer 42

a folate antagonist