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Rheumatology > Rheum Pharm: Lupus and Gout Meds > Flashcards

Rheum Pharm: Lupus and Gout Meds Flashcards

1
Q

Meds to avoid (may cause SLE exacerbation)

4

A

Sulfa containing antibiotics

  1. Sulfadiazine,
  2. trimethoprim/sulfamethoxazole
  3. Minocycline
  4. Oral contraceptives
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2
Q

Drug-induced lupus

3 most common?

A
  1. Procainamide
  2. Hydralazine
  3. Griseofulvin

These meds do not seem to cause exacerbations of idiopathic lupus but may cause drug-induced lupus

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3
Q

Medical therapy is targeted at the organ/system involvement

  1. Antimalarials work for what? 2
  2. Which drug?
  3. May prevent what kind of damage? 2
  4. May decrease what?
A
    • cutaneous and
    • MSK involvement
  2. Hydroxychloroquine (Plaquenil)
  3. May prevent renal and CNS damage
  4. May decrease disease flares
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4
Q

Other meds for cutanous manifesations of SLE other than antimalarials?

Musculoskeletal?

A
  1. Cutaneous
    Topical therapies whenever possible
  2. Musculoskeletal
    NSAIDs
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5
Q

SLE
Glucocorticoids for significant organ involvement
5

A
  1. Cardiopulmonary
  2. Hepatic
  3. Renal
  4. Hemolytic anemia
  5. Immune thrombocytopenia
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6
Q

SLE
Other immune modulators used for severe disease and when steroid resistant such as?
5

A
  1. Methotrexate
  2. Cyclophosphamide
  3. Azathioprine
  4. Mycophenolate
  5. Rituximab
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7
Q

If antiphospholipid antibody positive how should we treat?

A

Lifelong anticoagulation

Warfarin to achieve INR of 2-3

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8
Q

Gout medications? 4

A
  1. Indomethacin (Indocin)
  2. Colchicine (Colcrys)
  3. Allopurinol (Zyloprim)
  4. Probenecid
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9
Q

Pharmacologic management of gout
1. ACUTE ATTACK options?
(first through third line?)

  1. Prevention of attacks? 3
A
  1. NSAIDs #1
  2. Colchicine #2
  3. Steroids #3
  4. Avoidance of meds that increase uric acid
  5. Xanthine oxidase inhibitors
  6. Uricosuric drugs
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10
Q

Which NSAIDS would we used for acute gout attacks?

2

A
  1. Naproxen

2. Indomethacin

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11
Q

GOUT
Xanthine oxidase inhibitors
which drugs are these? 2

Uricosuric drugs: which drugs are these? 1

A
  1. Allopurinol (Zyloprim)
  2. Febuxostat
  3. Probenecid
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12
Q

GOUT

MOA of Xanthine oxidase inhibitors and Uricosuric drugs?

A

Decrease serum uric acid

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13
Q

General principles of gout treatment
1. Start medications when?

  1. Ok to stop treatment how long after symptom resolution unless on steroids then need a slower taper to prevent a rebound attack?
  2. Do not initiate what therapies in acute gout?
A
  1. as soon as patient perceives an attack coming on
  2. 2-3 days
  3. urate-lowering
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14
Q

Acute Gout
1. When would we use colchicine?

  1. When would we use corticosteriods? 2
A
  1. Colchicine
    - Use if contraindications to NSAIDs
  2. Corticosteroids
    - Use if contraindications to NSAIDs and Colchicine or
    - if other therapies fail to resolve symptoms
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15
Q

GOUT:
1. NSAIDs MOA:
Inhibit what? 2

  1. Contraindications? 6
A

In general inhibit

  • cyclooxygenase and
  • ultimately production of mediators of inflammation
    • CrCl less than 60 ml/min,
    • active duodenal or gastric ulcers,
    • heart failure,
    • uncontrolled HTN,
    • allergy,
    • chronic anticoagulation
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16
Q

GOUT: What specific mediators do NSAIDs indirectly inhibit? 3

A
  1. Prostaglandins,
  2. prostacyclin,
  3. thromboxane
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17
Q

GOUT
NSAIDs: Increased risk of what? 5

Naproxen at high doses does not seem to increase CV risks but at lower doses is similar to other NSAIDs
Risks seem to increase for long term use (> 1 month)

A
  1. stroke,
  2. MI,
  3. CHF,
  4. afib,
  5. CV death
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18
Q

GOUT
For patients on aspirin
When should we take NSAIDS?

A

Take ASA 2 hours prior to NSAID therapy

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19
Q

NSAIDs for acute gout
1. Key to symptom relief is what?

  1. ____ days of therapy is usual
  2. Can reduce dose if needed after what?
  3. Continue for about __ days after complete resolution of symptoms
A
  1. beginning treatment at the onset of symptoms
  2. 5-7
  3. good symptom response
  4. 2
20
Q

NSAIDs for acute gout
Which ones and at what dose?
3

A
  1. Indomethacin (Indocin)
    50mg TID
  2. Naproxen (Naprosyn, Naprelan, Aleve, Anaprox)
    500mg BID
  3. Celecoxib (Celebrex)
    800mg initial dose then decrease to 400mg BID
21
Q

GOUT
NSAIDs for acute gout:
Dont prescribe Celecoxib (Celebrex) if what?

A

Avoid if history of sulfa allergy

22
Q

GOUT
Colchicine (Colcrys) for acute attacks
1. Use when?
2. Most likely to be effective if what?
3. Not beneficial for attacks ongoing for more than what?
4. If loading dose within the last 2 weeks, don’t do what?

A
  1. Use if NSAID intolerance or contraindication
  2. Most like to be effective if treatment started within 24 hours of symptom onset
  3. Not beneficial for attacks ongoing for more then 72 hrs
  4. If loading dose within the last 2 weeks, don’t repeat it
23
Q 
GOUT
Colchicine (Colcrys)
1. Loading dose?
2. Followed by?
3. then (12 hrs later) move to dosing for prophylaxis of?
A
  1. Loading dose of 1.2 mg
  2. followed by a dose of 0.6 mg 1 hr later
  3. then (12 hrs later) move to dosing for prophylaxis 0.6 mg QD or BID
24
Q

GOUT
Colchicine for acute attacks:
If already on chronic colchicine and attack develops give a what?

A

loading dose

25
Q

GOUT
Colchicine
1. MOA?
2. Onset of action to pain relief?

  1. Metabolism?
  2. Half life?
  3. Time to peak serum concentration?
  4. Preg cat?
A
  1. MOA: Prevents activation degranulation and migration of neutrophils associated with mediating some gout symptoms
  2. Onset of action to pain relief: 18-24 hrs
  3. Metabolism: Hepatic via CYP3A4
  4. Half-life: 27-31 hours
  5. Time to peak serum concentration: 30min to 3 hrs
  6. Pregnancy cat: C
26
Q

GOUT
Colchicine SE
6

A
  1. Diarrhea up to 77%
  2. Nausea
  3. Vomiting
  4. Reversible peripheral neuropathy
  5. Bone marrow suppression
  6. Myopathy
27
Q

GOUT
Who is at risk for myopathy taking Colchicine?
7

A
  1. At risk if renal dysfunction,
  2. elderly or
    concomitant use of
  3. Cyclosporine,
  4. diltiazem,
  5. verapamil,
  6. fibrates,
  7. statins
28
Q

GOUT
Dose adjustment for colchicine needed
in who?

A
  1. > 70 years old
  2. CrCl less than 30 ml minute
  3. Avoid in dialysis patients
29
Q

GOUT

Colchicine Contraindications?2

A
  1. Renal impairment

2. Hepatic impairment

30
Q

GOUT
If no relief of symptoms with colchicine then what should we do?
2

A
  1. Add on a glucocorticoid

2. OR may be used cautiously in conjunction with an NSAID (if not contraindicated)

31
Q

Administration types for glucocorticoids in GOUT?

3

A
  1. Intraarticular
  2. Oral
  3. IV and IM
32
Q

GOUT

  1. Oral glucocorticoids when? 2
  2. What med and what dose?
  3. Why IV or IM?
A
    • For those who cannot take NSAIDs, colchicine and
    • not candidates for joint injection
  2. Prednisone 30-50mg daily until resolution then taper off over a week
  3. IV or IM
    If not a candidate for any other route or medication
33
Q

Management between gout attacks

2

A
  1. Avoidance of meds that increase uric acid or inhibit renal excretion of uric acid
  2. Uric acid reducing meds
34
Q

GOUT
When are Meds to reduce serum uric acid are indicated?
3

Avoidance of meds that increase uric acid or inhibit renal excretion of uric acid. SUCH AS? 3

A
  1. 2 or more episodes per year
  2. Tophi
  3. Chronic kidney disease, stage 2 or greater
  4. Thiazide and loop diuretics
  5. Niacin
  6. Aspirin
35
Q

GOUT preventative therapy:
1. Wait how long after an acute attack to initiate prevention therapy?

  1. Initiation of antihyperuricemic therapy can stimulate what?
  2. Lowering the uric acid levels how can stimulate a gout attack?
  3. Prophylactic _________ therapy is used when initiating urate lowering therapy to reduce attacks
  4. Dosing?
A
  1. 2 weeks
  2. a gout attack
  3. too quickly
  4. colchicine
  5. Colchicine 0.6mg Qday to BID
36
Q

What is the agent of choice for urate lowering?

A

Allopurinol (Zyloprim)

37
Q

Allopurinol (Zyloprim)

  1. Class of drug?
  2. Goal for seruem urate level is what?
  3. Check when after dose adjustment?
  4. Recheck in how long to confirm?
  5. Recheck how often after that?
A
  1. Xanthine oxidase inhibitor
  2. Goal for serum urate level is less than 6
  3. Check 2-4 weeks after dose adjustment
  4. Recheck in 3 months to confirm
  5. Recheck q 6 months to yearly
38
Q

Allopurinol (Zyloprim)

  1. MOA?
  2. Onset of action?
  3. Half life?
  4. Adjust dose for renal impairment how? 2
  5. Normal adult dosing?
A
  1. MOA: Inhibits xanthine oxidase needed for the eventual conversion of hypoxanthine to uric acid
  2. Onset of action: 1-2 weeks
  3. Half life: active metabolite 18-30 hrs
  4. Adjust does for renal impairment
    - 100mg daily for CrCl >60 ml/min
    - Lower dose for CrCl
39
Q

Allopurinol (Zyloprim) SE?

8

A
  1. Skin rash *D/C drug
  2. Gout attack
  3. Diarrhea
  4. Nausea
  5. Elevated liver enzymes
  6. Hypersensitivity reactions*
  7. Bone marrow suppression
  8. Hepatotoxicity
40
Q

Allopurinol (Zyloprim)
Hypersensitivity reactions* with what? 3

What should we be aware of with Bone marrow suppression?

A
  1. ACEI
  2. Amoxicillin/ampicillin
  3. Diuretics

Use with caution with other drugs that cause myelosuppression

41
Q

Preventative Gout med:

Second line agent if unable to take allopurinol?

A

Probenecid

42
Q 
GOUT
Probenecid
1. Class?
2. MOA?
3. Not effective if what?
4. Contraindicated when?
A
  1. Uricosuric agent
  2. Blocks tubular reabsorption of filtered urate and increases uric acid excretion by the kidney
  3. Not effective if CrCl
43
Q

GOUT:
Probenecid
To prevent the development of uric acid stones
2

A
  1. Patient education to increase fluid intake

2. May need an agent to alkalinize the urine - potassium citrate to maintain urine pH > 6.0

44
Q

GOUT: These meds can also decrease uric acid levels. Such as? 4

A
  1. Losartan
  2. Fenofibrate
  3. Vitamin C 500mg daily
  4. Cherries
45
Q

Take home points on NSAIDs and steroids
1. Remember they cause what? 3

  1. Need to monitor closely for _______ in patients at high risk for fluid retention and may need to adjust usual ________ doses during treatment
A
    • fluid retention
    • HTN
    • significant CHF exacerbations
  2. edema, diuretic

Many, many hospital admissions for CHF have been caused by administration of these meds

Rheumatology (11 decks)

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