Drugs for Osteoarthritis/ Drugs used in Rheumatoid Arthritis (MDM)

What do you give a patient with rheumatoid arthritis not respond to methotrexate?

Leflunomide -as effective as methotrexate at reducing disease activity/progression (give with methotrexate)

What is generally the first DMARD prescribed? (first-line) How level of severity is it used in?

Methotrexate - any level of severity (mild/moderate/severe)

Duloxetine MOA

selective serotonin and NE reuptake inhibitor - approved for treatment of chronic MSK pain

Review DMARDs classifications List the non- biological and biological

(note: gold compounds not included in our list)

What is Rheumatoid arthritis?

- autoimmune disease - driven by activated T-cells (giving rise to cytokines)

Moderate to severe of RA what do you give?

- combine biological DMARD w non-biological DMARD for initial treatment (TNF-alpha inhibitors are first line)

Glucocorticoids - when do you give to RA patients?

- effective for symptomatic relief until DMARDs can have effect

Sulfasalazine - used for? - how long does it take to act?

- for rheumatoid arthritis - can take 2-3 months

Intraarticular corticosteroids - who can you give it to? - what agents are commonly used (2)

- in patients w/ persistent symp in one or a few joints (inject into the joints) -Agents 1) Betamethasone 2) Triamcinolone

Hydroxychlorquine -what severity level of rheumatoid arthritis? -other important info

- moderatly effective for mild rheumatoid arthritis - lest toxis DMARD - least effective DMARD (often used with other drugs; esp methorexate and sulfasalazine) - could require 3-6 months too see effect

Azathioprine - used for?

- ppl w/ refreactory rheumatoid arthritis

How do NSAIDs and corticoids rheumatoid arthritis?

- reduce pain/inflammation - cortoids can reduce joint symp and control systemic issues *they do NOT prevent progression of the disease or joint destruction*

Cyclosporine - used for? - AE?

- rheumatoid arthritis - *Nephrotoxicity* and can have food/ drug interactions

Capsaicin

- topical application can reduce osteoarthritic pain in some ppl - AE: can cause severe burns and nerve damage at site of application - AE: dried residue can cause coughing, sneezing and eye irritation

Cyclophosphamide - used for? - AE?

- use limited to most severe cases of rheumatoid arthritis - long term risk of malignancy and infection (think; bc of immunosupression)

Combination therapy for RA

-usually includes weekly methotrexate with other therapies added - hydroxychloroquine has low toxicity and often used with other drugs (especially metotrexate and sulfasalazine)

What is the max biological DMARDs that should be given

1 (only use 1 at a time or will increase risk of infections)

What are the category of drugs used to treat osteoarthritis? (7)

1) Acetaminophen 2) NSAIDs (diclofenac-topical) 3) Duloxetine 4) Tramadol 5) Opioids 6) Capsaicin 7) intraarticular corticoids

What are the 3 classes of drugs used in the treatment of rheumatoid arthritis?

1) NSAIDs 2) Glucocorticoids 3) DMARDs (mixed family of drugs specific for Rhematoid arthritis- disease modifying anti-rheumatic drugs)

Name the 3 anti-TNF drugs

1) adalimumab 2) infliximab 3) etanercept

What opioids are used in intractable osteoarthritis pain? (3)

1) hydrocodone 2) morphine 3) oxycodone

DOC for initial treatment of RA?

1) non biological DMARD (usually methotrexate) plus NSAID or corticoid to control symp

What 2 factors does the choice of treatment depend on?

1) severity of the disease 2) presence/absence of inflammation

Anti-TNF alpha drugs 1) affect is mediated by? 2) how long do they take to act? 3) what are they usually used with?

1) specific membrane bound TNF receptors (TNFR1 and TNFR2) 2) acto more quickly then nonbiological DMARDs 3) Methotrexate; when used in combination have synergist effects

When should NSAIDs be used for osteoarthritis?

1) when acetaminophen does not work OR 2) When osteoarthritis is inflammatory (can be used instead or w/ acetaminophen)

How long to DMARDs take to show clinical effects?

6weeks to 6months (note some biological ones can be active in less than 2 weeks)

What can be used in ppl who did not respond to nonbiological DMARDs or anti-TNF agents?

Abatacept

What is the first line treatment for mild to moderate osteoarthritis w/ out inflammation?

Acetaminophen (less effective then low doses of NSAIDs but fewer AE)

What class of drugs used in rheumatoid arthritis helps reduce/prevent further damage of the joints?

DMARDs (no immediate analgesic effect)

What do you use when NSAIDs and acetaminophen have have failed?

Duloxetine (second-line)

Diclofenac - type of drug - who to use it in

NSAID - available as topical gel/ solution - used in ppl with only a few joints or ppl at high risk for AE

What can be used in the mildest cases of RA?

Hydroxychloroquine or sulfasalazine

What drug can be used to prevent the progression of osteoarthritis?

None (can only treat symptoms)

What is used for moderate to severe chronic/osteoarthritic pain in adults?

Tramadol

NSAIDs in RA

have immediate anti-inflammatory and analgesic effect

Leflunomide with methotrexate increases risk for what?

hepatotoxicity (must monitor)

Anakinra - used for?

moderate to severe RA (modestly effective)

When should biological DMARDs be used?

moderate to severe cases

Rituximab

non biological DMARD - used w methotrexate

What is the last resort treatment for intractable osteoarthritis pain?

opioids

What other condition is methotrexate used for and how do the doses vary?

used in cancer - cancer requires larger dose which changes MOA