RA- Drugs Flashcards
When are nsaids considered for RA
They are considered after
- paracetamol and life style meausres have not worked
- Consider a low dose NSAID for the shortest duration
- If therapy with lower dose doesnt work then increase to a higher does NSAID for shortest term
Precautions/Considerations for NSAIDS
Precautions- (D,A,C,C,S,E)
- Dehydration- nsaids inhibit
prostaglandins that are important in
maintain renal blood flow)
- Asthma- can cause broncho constriction
and precipitate worsening asthma
- Coagulation disorders - increased risk of
bleeding
- Cardiovascular-use with caution
- Renal impairment - use with caution
- Surgery - has a risk of renal impairment
due decreased renal blood flow
especially if patient is dehydrated. Make
sure patient is well hydrated ( via drip)
especially if they are going to be started
on an naiad
- Elderly - increased risk of adverse effects GIVE LOWER DOSE
CONTRAINDICATED- NO USE (G- CHAP)
- Cardio vascular - if patient has heart failure , Post MI (due to increased risk of mortality ),
-Gastric- Patient has active peptic ulcer
or GI bleeding
Avoid it patient has a history of GI
bleeding
- Pregnancy/BREASTFEEDING- AVOID
USE- causes miscarriage
- in Breastfeeding it is okay and safe to
use - ibuprofen recommended short
term
-Hepatic DISEASE- in sever disease stage ( in liver cirosis tage)
-Asthma- if asthma is uncontrolled cease NSAID- can make it worse
what are the doses for nsaids
COx1 and 2
- ibuprofen 200-400mg every 6-8 hours max2400mg
- naproxen 275-550(250-500mg) BD( 1250mg max)
NB- psudoporphyria( skin blistery lesions common)
-Asprin -
-Dicofenac (75mg-150MG) 3-4 divided doses ( every 6-8 hours)
MAX 200mg (8 x25mg or3x50mg) (50 mg t.i.d. or q.i.d., or 75 mg b.i.d.).
- Indomethacin 25-50mg- 2-4 dived dose
(every 6-12 hours) - Mefanamic acid-500mg tds
COx2
- Meloxicam 7.5-15mg ONCE d
- Celecoxib 100 bd initially then can be
increased to 200mg bd short term
* 400mg day 1 then 200mg bd- period pain and post opp pain)*
Cardiovascular events are dose dependent, Don’t use 200mg> more than 5 days
What are the main adverse effects for NSAIDS
Nausea
Dyspepsia
Gi ulceration/ bleeding
LIver enxymes( diclofenac)
Hypertension
Fluid retention
RAre-
hypersentivity ( asthma, angiodema, urticaria)
SJS
Renal imp
Counselling points for NSAIDS
increase hydration due to increase dehydration
MAke sure to check BP
Take with food due to stomach upset
- what are the Corticosteroid available
prednisolone or prednisone
- prednisone gets converted to the active
metabolite prednisolone via liver
enzymes
Prednisolone over prednisone for pt with liver disease
What are the precautions/Contraindications for Steroids
PRECAUTIONS
DGOHT - TH-GOD
-Diabetes- can cause an increase in blood sugar levels
-Glaucoma- Can increase intra ocular pressure
-Osteoporosis- Long term Can increase osteoporotic fractures
-Hypertension/HF- Can cause in crease in bp and worsening of hf( Due to water retention )
-TB- LATENT - may be activated
-Peptic ulcer disease - Can increase risk
PREG/BREASTFEEDING- avoid in first trimester , use alternative if possible-
Old literature suggest steroid usage in early trimester can lead to cleft lip, preterm birth and low birth weight
- Weigh out pros vs cons
-low dose for shortest time
Children- chronic use can retard growth if given to kids earlier
What are the adverse effects corticosteroids steroids
NB - adverse effects occur with prolonged use and with higher doses
- Common- Adrenal suppression
C- cushingiod apperance ( swollen face ,
Hunch back,
central fat
O -oedema
R retardation of growth
T- Thinning on skin , increased bruising delayed would healing, flushing
I - Immunosuppression- increased infection
C-cataracts
O - osteoporosis- ( increase risk of
osteoportatic fracture
due to it decreasing
absorption of calcium
form git
S - suppression of adrenal glands-adrenal crisis if stopped abruptly- need to tapper down doses
T -teratogenic- Avoid in first trimester (first 12 weeks)
E - emotion disturbance- Anxiety,depression, mood swings, sleep disturbances
R - raised blood pressure
O Obesity- weight gain
I-increased body hair, appetite
D- diabetes- hyper glycemia
S- straie- stretch marks that are red / purple
What are the councelling points for Steroids
-Take it with food
-Monitor for increased of infections
-Do not stop abruptly - due to withdrawal and adrenal crisis
-if you are having mood changes, psychiatric effect go to doctor
- At base line - MOnitor - bp, BGL, BMD, Weight,
What are sx of adrenal crisis
MEDICAL EMERGENCY
- lightheadedness / dizziness
- abdominal pain
-weakness
- sweating
- loss of consciouness
- If tapering is conducted too quickly can
have with drawl sx- body aches
- Fatigue
- Weakness
what are the sDMARDS
methotrexate , sulfasalizine, lufonamide, hydrochloroquine
- what is first line treatment
Patient to be started on sulfasalizine or hydroqloroquine at mild disease stage
Sulfasalizine may be better tolerated that hydroqqloroquine
What is sulfasalazine (SULFUR=YELLOW)
Its a 5ASA- amino salicylate
- Belongs to the -Salazine Family
what are the Contraindications of sulfasalazine
Allergy to salicylates -( all the 5-ASA and Aspirin
What are the precautions for Sulfasalizine
Allergy to aspirin
6Gpd (x linked disorder)
Blood dycrasasia- increased risk of
myelosuppression
Asthma- a sever allergy to 5ASA can exacerbate asthma
What is the dose of Sulfasalazine
- 500mg ONCE a day- Can increase by 500mg weekly until a maximum of 3 g is taken in 3-4 dived doses
Maintenance dose - 2-3 g in 2-3 doses
What are the adverse effects of sulfasalazine
Adverse effects are usually associated with high dose.
MAINLY GI side effects
c -nausea, vomiting, rash , reversible male infertility
Infrequent- Staining YELLOW of bodily fluids/skin- urine, skin, contact lenses
what dose sulfasalazine impair
(starts with f)
Impacts folic acid absorption-
patients need supplementation of 5mg daily
what are the counselling points associated with sulfasalazine
- Take it with food to lessen the GI side
effects
What is Hydroxychloroquine
it is an ant inflammatory with immunosuppressive effects
What are the precautions / Contraindication of Hydroxychloroquine
Precautions
- OCCULAR conditions - if patient has cataracts may affect eye examinations increasing risk of retinopathy
- Prolong qt interval risk worsening
arrhythmia
- Diabetes - may lower the HbA1c- due to
hypoglycaemia - monitor bgl and adjust
dose of antidiabetic
- Psoriasis- may be exacerbated and increase skin flares
- Haematological disorders- may be
myelosuppressive
Contraindications
- Allergy to quinolones
- OCCULAR Conditions- is patient has maculopathy
What are the the main adverse effects associated with hydroxychloroquine
Common- GI side effects - nausea, vomiting, diarrhoea
+
OCCULAR effects ( due to oedema and
opacity )
Rentinopathy was attributed to dosing and duration of treatment
what is the normal dose of Plaquinel
RA- 200-400mg daily for 1-3 months until response
- use minimum effective dose
What are the main counselling points with Hydroxychloroquine
This medication can impact vison hence if affected no driving
Take this medication with food to help with GI side effects
Advised to wear sunglasses to protect eyes from the sun
Describe the OCCULAR TOXICITY and SCREENING procedures of Plaquenil
Main aim of retinal screening:
is to identify early retinal damage ( scotoma ) and able to stop drug therapy early before permanent full vison is lost
Make sure at base line patient has there eyes checked
and then ANNUAL eye checks are mandatory
Methoo
Fv
