Duke PA Rheumatology Pharmacology Flashcards

Terms Definitions
The safest initial approach to treat OA is to use __
a simple oral analgesic such as acetaminophen (perhaps in conjunction with topical therapy
If pain relief with acetaminophen is inadequate for pain control in OA, __
oral nonsteroidal anti-inflammatory drugs or intra-articular injections of hyaluronic acid­like products should be considered
__ may provide short-term pain relief in disease flares
Intra-articular corticosteroid injections
Alleviation of pain does not __
alter the underlying disease
has been associated with decreased pain and improved quality of life
participation in arthritis self help courses taught by allied health professionals
One study found that __ were cost-effective and were associated with good clinical outcomes
monthly telephone communications with patients
the available evidence shows that __ does not increase the development of osteoarthritis
regular low-impact exercise of osteoarthritic joints
The goals of an exercise program are to __
maintain range of motion, muscle strength and general health
All patients with osteoarthritis of the knee should be taught __ and should be encouraged to perform them every day
quadriceps-strengthening exercises
Patients with osteoarthritis who participate in an aerobic exercise program have been shown to have improved __ , compared with patients who only perform range-of-motion exercises
aerobic capacity and 50-ft walking times, as well as decreased depression and anxiety
Many patients with osteoarthritis of the hip and knee are more comfortable __
wearing shoes with good shock-absorbing properties or orthoses.
The use of an appropriately selected __ can reduce hip loading by 20 to 30 percent
cane
At present, these supplements cannot be recommended for use in the treatment of osteoarthritis
glucosamine sulfate and chondroitin sulfate
The recognition that pain in osteoarthritis is not necessarily due to inflammation has led to an increased awareness of the role of __ in the treatment of this disease.
simple analgesics
The ACR guidelines emphasize the use of __ as first-line treatment for osteoarthritis of the hip and knee
acetaminophen
__ can be used for short periods to treat exacerbations of pain
Opioid-containing analgesics, including codeine and propoxyphene (Darvon)
These agents are not recommended for prolonged use because they cause constipation and increase the risk of falling, particularly in the elderly
Opioid-containing analgesics, including codeine and propoxyphene (Darvon)
In patients requiring NSAID therapy, concurrent use of __ may allow the NSAID dosage to be reduced, thereby limiting toxicity
acetaminophen
it is important to monitor renal and liver function when prescribing __
NSAIDs
__, has been shown to be better than placebo in relieving the pain of osteoarthritis
Capsaicin (e.g., ArthriCare), a pepper-plant derivative
Patients with a painful flare of osteoarthritis of the knee may benefit from __
intra-articular injection of a corticosteroid such as methylprednisolone (Medrol) or triamcinolone (Aristocort
When a joint is painful and swollen, short-term pain relief can be achieved with __
aspiration of joint fluid followed by intra-articular injection of a corticosteroid
A joint should not be injected more than __ times in one year because of the possibility of cartilage damage from repeated injections
3-4
Patients who require more than three or four injections per year to control symptoms are probably candidates for __
surgical intervention
Patients with painful osteoarthritis of the hip may benefit from __
intra-articular corticosteroid injections. These injections should be performed under fluoroscopic guidance
__ is a major nonstructural component of the synovial and cartilage extracellular matrix
Hyaluronic acid
In patients with osteoarthritis, the concentration and the molecular weight of __ are decreased
hyaluronic acid
Gout is caused by __ crystal deposition in tissues leading to arthritis, soft tissue masses (i.e., tophi), nephrolithiasis, and urate nephropathy
monosodium urate
First-line therapy for acute gout is __ or __, depending on comorbidities;
nonsteroidal anti-inflammatory drugs, corticosteroids
second line therapy for gout
colchicine
after the first attack of gout, modifiable risk factors should be addressed, these risk factors are
high-purine diet, alcohol use, obesity, diuretic therapy
__ therapy for gout is initiated after multiple attacks or after the development of tophi or urate nephrolithiasis
Urate-lowering
__ is the most common therapy for chronic gout
Allopurinol
__ agents are alternative therapies in patients with preserved renal function and no history of nephrolithiasis
Uricosuric
__ are infection; intravenous contrast media; acidosis; and rapid fluctuations in serum uric acid concentrations
Common triggers for acute gout
stopping or starting allopurinol
can cause a rapid fluctuations in serum uric acid concentrations, leading to acute gout
Occasionally, first line therapies for gout may need to be supplemented by __
short-acting opioids such as hydrocodone (Hycodan) and oxycodone (Roxicodone).
About __ percent of persons who experience a gout attack will have another attack within 12 months
60
nonpharmacologic treatment of __ should begin with the first gout attack and should initially focus on modifiable risk factors
hyperuricemia
__ is recommended for patients with more than two gouty attacks per year, in patients with tophi, and in patients with joint damage seen on a radiograph
Urate-lowering pharmacotherapy using a xanthine oxidase inhibitor or uricosuric agent
__ therapy should not commence until the acute phase of gout has completely resolved because fluctuations in serum uric acid levels will exacerbate the inflammatory process
Urate-lowering pharmacotherapy using a xanthine oxidase inhibitor or uricosuric agent
When initiating urate-lowering therapy, concurrent prophylaxis with __ has been shown to reduce the risk of flare-ups
low-dose colchicine (0.6 to 1.2 mg daily) for three to six months
__ is the first-line urate-lowering therapy
Allopurinol
Approximately 2 to 5 percent of patients taking allopurinol have __ and other adverse effects
minor rashes
Those intolerant of allopurinol may undergo desensitization or may take __
oxypurinol (the active metabolite of allopurinol)
__ are second-line therapy for patients who are intolerant of allopurinol, or they may be used in combination with allopurinol in patients with refractory hyperuricemia
Uricosuric agents
__ is the uricosuric agent most often used in the United States
Probenecid
Uricosuric therapy is contraindicated in patients with a history of __
nephrolithiasis and is ineffective in those with a creatinine clearance of less than 50 mL per minute (0.83 mL per second).
__ have uricosuric properties and may be useful adjunctive therapies for patients with gout, hypertension, and hyperlipidemia
Losartan (Cozaar) and fenofibrate (Tricor)
goals of treatment for gout
acute event treatment, prevention of further attacks
caused by overproduction ro underexcretion of uric acid
gout
__% of gout patients are underexcretors of uric acid
90
humans lack the enzyme needed to break down __
uric acid
treatment for acute gout attack
NSAIDs
FDA approved NSAIDs for use in acute gout attack
indomethacin, sulindac, naproxen
inexpensive NSAID with minimal side effects
ibuprofen
NSAID with least GI side effects
nabumetone
NSAID with least renal toxicity
suldinac, nabumetone
NSAID with greates ability to prevent uric acid from being reabsorbed (expensive)
diflunisal
NSAIDs are contraindicated in those with
peptic ulcer disease, anticoagulation
GI bleeding, ulcer development, perforationsRenal toxicityLiver dysfunctionEdema, hypertensionDiarrhea, constipation, indigestion, nauseaDizziness, headache, somnolence
NSAID AE's
if patient has monoarticular involvement with gout __ is the prefered treatment
intra-articular corticosteroid
Oral corticosteroids used for gout
prednisone
Used only when NSAIDs, colchicine are not effective
oral corticosteroids
IM corticosteroids used for doubt
triamcinolone acetonide, methylprednisolone
HyperglycemiaInsomnia, restlessnessIncreased appetitePeptic ulcer/ bleedingOsteoporosisGlaucomaEdemaImpaired wound healingMyopathy
corticosteroid AE's
Most beneficial if started within 36 hours of acute attack
colchicine
colchicine is contraindicated in patients with
moderate to severe renal or hepatic disease and severe cardiac disease
Reduces lactic acid production in leukocytesDecreases urate crystal depositionUrate crystals are formed in low-pH environmentsReduces phagocytosisDecreases inflammationDoes not have analgesic or uricosuric effects
Colchicine
Onset of action 12 hoursElimination via biliary and renal (20%) routesRequires renal dose adjustments
Colchicine
GI (80% of patients)Nausea, vomiting, diarrhea, abdominal painAlopeciaAnorexiaBone marrow suppressionMyopathyDeath (cardiac, renal)
Colchicine AE's
Should not be initiated during an acute gout attackFluctuations in uric acid levels increase inflammation during an acute attack
Chronic Gout Urate-lowering Therapy
Initiate 4-6 weeks after acute attack in patients with frequent attacks (>2/year) or those with complications
Chronic Gout Urate-lowering Therapy
biggest AE to look out for with allopurinol
skin rash
mechanism of action of probenecid
inhibits the tubular reabsorption of urate at the proximal convoluted tubule
HeadacheNausea, vomitingHypersensitivitySore gumsMyelosuppressionExacerbation of gout
Probenecid AE's
Kidney stonesCrCl < 50 ml/min ineffective
Probenecid contraindications
May be used while titrating urate-lowering therapy to prevent flare upsDose is one 0.6mg tablet daily Use for 3-6 months
Colchicine
considered first line for OA
acetaminophen
Hepatic toxicityRashRenal toxicity GI bleedingMyelosuppression
acetaminophen AE's
don't drink alcohol and take
acetaminophen
a thin layer of capsaicin must be applied __ times daily for effect
3-4
results may take up to 2 weeks for
capsaicin
topical analgesic
methylsalicylate (icy hot, bengay)
topical NSAID
diclofenac gel
when using NSAIDs to decrease the risk of GI bleed __ may be used
Proton Pump Inhibitor
only COX-2 inhibitor left on the market
Celecoxib (Celebrex)
contraindication of Celocoxib
sulfonamide allergy
Headache, dizziness, insomniaEdemaGI upset (diarrhea, nausea, abdominal pain)Upper respiratory illnessBackache RashMI (<2%), CVA
Celecoxib AE's
COX-2 inhibitors that were withdrawn from the market
Vioxx, Bextra
if a patient is taking Celecoxib as well as aspirin or warfarin
the GI protective effect is erased
next step before going to controlled opioids
tramadol (ultram)
FlushingDizziness, headache, insomnia, somnolenceItchingConstipation, nausea, vomiting, GI upsetWeaknessOrthostatic hypotensionSeizureHallucinations
Tramadol AE's
Opioids are used for
those in severe pain, unable to tolerate NSAIDs or tramadol
Itching, rashConstipation, nausea, vomitingUrinary retentionRespiratory depression
Opioid AE's
if a person is constipated while on opioids use a
stimulant laxative
mush without a push
stool softener without a stimulant laxative with opioid use
Used for those with OA of the knee who have not responded to non-pharmacologic and analgesic treatments
intra-articular therapy
maximum of __ injections of glucocorticoids per year
4
glucocorticoid injection effects last __ weeks
4-8
Hyaluronic acid injection effects last up to __ months
6
__ is administered by injection once weekly for 3-5 weeks
hyaluronic acid
Injection site (pain, swelling, bruising)Respiratory infection
hyaluronic acid injection AE's
when trying glucosamine or chondroitin, discontinue if no response after __ months of use
6
limited oral absorption 0-13%
chondroitin
goals of treatment for RA
acute treatment of flare-ups, chronic disease-modifying treatment
disease modifying anti-rheumatic drugs
DMARDs
Initial treatment, bridge therapy for RA
NSAIDs
Should not be the sole treatment for RADo not alter the disease courseDo not prevent joint destruction,RA patients are twice as likely to have serious complications as OA patients
NSAIDs
Osteoporosis CV risk- weight gain, edema, HTN, atherosclerosisHyperglycemiaSkin fragilityGI bleedingCataractsCushing’s syndrome
long term AE's of Glucocorticoids when treating RA
if patients with RA are on more than 5mg of prednison daily they need
vitamin supplements-1500mg calcium, 400-800 IU vitamin D, bisphosphonates (age >65, h/o fracutre)
Should be initiated within 3 months of diagnosis of RA
DMARDs
Reduce and prevent joint damagePreserve joint integrity and functionReduce total healthcare costsMaintain economic productivity of patientwith RA
DMARDs
Gold standard DMARD
methotrexate
contraindications of methotrexate
pregnancy, severe renal or hepatic impairment
Nausea, vomiting, diarrhea, anorexiaAlopecia, rashMyelosuppressionLiver, renal failureHyperuricemiaOral ulcersCough, SOB (pulmonary fibrosis
methotrexate AE's
patients taking methotrexate should avoid
alcohol
patients taking methotrexate should also take __ as it reduces toxicity and GI effects
folic acid
elimination of this drug may take up to 2 years
leflunomide
Diarrhea (32%), weight loss (up to 20%)HTN (18%)Alopecia, rashElevated LFTsRespiratory tract infection
Leflunomide AE's
don't give this drug to premenopausal females if it can be helped
Leflunomide
Women AND men who wish to conceive must undergo __ washout when taking leflunomide
cholestyramine
Benefits shown in 1-6 monthsDoes not slow radiologic damageShould not be used as monotherapyBest tolerated DMARD200mg BID
Hydroxychloroquine
Nausea, vomiting, diarrheaMyopathyHeadache Disorder of cornea, retinopathy*AgranulocytosisSkin pigmentation
Hydroxychloroquine AE's
Onset of effect within 1-3 monthsSlows radiographic progression
Sulfasalazine
HeadachePhotosensitivity, rash*, yellow-orange discoloration*Nausea, vomiting, diarrhea, anorexiaMyelosuppressionLiver and kidney failureOligospermia*
Sulfasalazine AE's
Contraindications- active infections (TB skin test before initiating therapy), HF (infliximab
Anti-TNFα
very costly, but may be worth the cost due to efficacy
Anti-TNFα
Useful in those unable to tolerate TNF agentsContraindications- active infectionsDaily SQ injection
Anakinra
HeadacheInjection/Infusion site reactionRespiratory tract infection, rhinitisAbdominal pain, vomitingMyelosuppression
Anti-TNFα AE's
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