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104 Cards in this Set
- Front
- Back
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Non-drug treatments (4)
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1. weight loss
2. physical therapy & activity (use it or loose it) 3. devices (e.g. walking sticks) 4. arthritis self-management course |
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When do you start treatment & what is the aim of treatment
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Start when patient requests symptom relief
Aim is to reduce symptoms and maintain/improve joint function |
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What is the treatment step ladder for osteoarthritis
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1. Paracetamol
2. Consider topical NSAID, capsaicin, rubifacient 3. NSAIDs (first prn, low dose) 4. Consider intra-articular corticosteroids or intra-articular hylans 5. Higher dose NSAID 6. Orthopedic review & oral opioids e.g. tramadol |
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What about glucosamine for cartlidge?
1. dose 2. evidence for what joint 3. what clinical outcomes 4. cautions/CIs |
1.5g d: most evidence for knees
1. moderately reduces symptoms (some studies found it to be as effective as an NSAID) 2. Reduces radiological progression of the disease!! Caution: shellfish allergy |
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Is paracetamol as good as an NSAID?
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It MAY BE as good as an NSAID, esp for mild-mod disease.
It is better tolerated |
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NSAIDS
- MOA |
Inhibit COX (cyclo-oxygenase), which produces prostaglandins.
COX-2 inhibition reduces inflammation and pain COX-1 reduces gastric cytoprotection and has antiplatelet activity Inhibition of COX-1&2 reduces renal blood flow and GFR |
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How do NSAIDs reduces GFR?
(Cf. ACEIs) |
Ihibition of production of prostaglandins which cause vasodilation of the anterior renal arteriole
ACEIs inhibit angiotensin mediated vasoconstriction of the posterior renal arteriole |
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Why do we use low dose aspirin?
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Low dose aspirin has ~0% systemic bioavailability: it is metabolised in the liver. While in the hepatic portal vein, aspirin can act as an antiplatelet on RBCs: it irreversibly blocks COX-1 in platelets (live about 7 days). This prevents inhibition of COX in arteries and veins, which normally inhibit clotting processes.
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NSAIDs
Indications |
1. Pain, especially due to inflammation (e.g. dysmenorrhoea, renal colic, bone pain, post operative pain, migraine, headache)
2. Fever 3. Inflammatory conditions (acute gout, R.A., orther inflammatory arthropathies such as ankylosing spondylitis, psoriatic arthritis) 4. Osteoarthritis |
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NSAIDs
Contraindications |
1. Active peptic ulcer disease
OR ANY GI BLEEDING 2. Allery 3. COX-2 when patient has high CV risk (e.g. if they take aspirin) |
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ASPIRIN
Has (a) extra indications (b) an extra contraindication |
(a)
1. inhibition of platelet aggregation 2. Kawasaki's disease (systemic vasculitis occurring primarily in children <8) 3. Rheumatic fever (b) Haemophilia - this is only a caution with other NSAIDs (c) Not indicated for inflammatory conditions, except R.A. on specialist advice |
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What is rheumatic fever?
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a subacute febrile syndrome occurring after group A *-hemolytic streptococcal infection (usually pharyngitis) and mediated by an immune response to the organism; most often seen in children and young adults; features include fever, myocarditis (causing tachycardia and sometimes acute cardiac failure), endocarditis (with valvular incompetence, followed after healing by scarring), and migratory polyarthritis
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Cautions for NSAIDs
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1. Asthma, especially with rhinitis or nasal polyps
2. IBD (may worsen) 3. Hx of GI bleeding 4. Coagulation disorders (nonselectives increase risk of bleeding, Cox-1 inhibitors increase risk of thrombosis) 5. Low dose apirin (ibuprofen may reduce aspirin's antiplatelet action, aspirin negates COX-2 gastroprotective effects) 6. Heart disease: can increase blood pressure, increase oedema in HF, increase thrombosis (COX-2 and poss diclofenac) 7. Surgery: (a) Increased bleeding risk with nonselective NSAIDs, stop 2-3 days before (aspiring 1 week before) (b) post-op RF risk: ensure good hydration, particularly with laparoscopy and laparotomy |
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NSAIDs
- Pregnancy - Breastfeeding |
BF - Non-selective NSAIDs are safe to use; limited data about COX-2s; avoid aspirin due to theoretical risk of Reye's syndrome (single doses can be taken)
Pregnancy CAT C: (a)Early pregnancy: increased risk of miscarriage, (b)Late pregnancy: premature closure of fetal ductus arteriosus, fetal renal impairment, decreased amniotic fluid, delay labour, delay birth, increase bleeding - specialist use only after 34 weeks <150mg/day aspirin are "considered safe" |
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What is Reye's syndrome?
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an acquired encephalopathy of young children that follows an acute febrile illness, usually influenza or varicella infection; characterized by recurrent vomiting, agitation, and lethargy, which may lead to coma with intracranial hypertension; death can occur
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What is the ductus arteriosus?
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a fetal vessel connecting the left pulmonary artery with the descending aorta; in the first two months after birth, it normally changes into a fibrous cord, the ligamentum arteriosum; persistent postnatal patentcy is a correctable cardiovascular handicap.
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What is another reason why NSAIDs are not cool in women?
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May impair fertility by preventing or delaying ovulation
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NSAIDs in
(a) hepatic impairment (b) renal impairment |
(a) Caution in severe impairment due to increased bleeding risk (remember the oesophageal varices)
(b) avoid in mod-severe RI due to increased renal impairment and bleeding risk; aspirin may worsen; aspirin may worsen GI and bleeding effects due to uraemia |
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NSAID A/Es
(a) Explain relative GI adverse effects |
COX-2 lowest (benefit lost when used with low dose aspirin)
Diclofenac and LOW DOSE ibuprofen appear lower risk Ketoprofen and pirosicam appears highest risk |
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NSAIDS A/Es
(b) Explain relative VTE risk |
COX-2 highest risk - CI in high CV risk patients (esp when not taking low dose aspirin)
Diclofenac and indomethacin associated with increased CV risk also Naproxen not associated with increased CV risk |
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NSAIDs - A/Es
(a) common (b) infrequent (c) rare |
(a)
-nausea, dyspepsia, diarrhoea, GI bleeding - headache, dizziness - hypertension, salt and fluid retention (b) heart failure, oesophageal ulceration, rectal irritation with suppositories, HYPERKALAEMIA, bronchospasm (c) blood dyscrasia, ARF, SJS, TINNITUS, aseptic meningitis |
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Which NSAIDs are COX-2 selective?
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Meloxicam at low doses
Celecoxib Parecoxib |
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Do enteric formulations reduce GI ulceration?
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NO
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Do rectal formulations reduce GI ulceration?
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NO
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Which NSAIDs are available as suppositories?
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Indomethacin
Ketoprofen Diclofenac |
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Are topical NSAIDs any good?
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They are more effective than placebo. They achieve the highest tissue concentractions. Their efficacy against paracetamol has not been studied. Infrequently cause skin irritation.
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Which NSAIDs are available topically? Brand names, strengths?
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Diclofenac (Voltaren gel, 1%)
Piroxicam (Feldene gel, 0.5%) Ibuprofen (Nurofen, fel, 5%) Ketoprofen (Orudis gel, 2.5%) |
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Which NSAIDs are available IV&IM? are they also available orally?
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Ketorolac (also oral)
Parecoxib (not oral) |
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Which NSAIDs are available as daily doses? Which NSAID has the longest half-life and what is it?
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Celecoxib (1-2 d.d., 4-15hr)
Piroxicam (D, 30-50 hours) Ketoprofen (D, CR formulation, half life is 1.5-2hr) Meloxicam (20hr half life) Parecoxib (single post op dose) Sulindac (d @ 16hr SR, bd @7hr half life IR formulation) |
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What percentage will respond to any one NSAID?
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60%
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How long will it take to see a maximal response from an NSAID in OA?
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2 weeks; trial for 3 weeks
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NSAID+aspirin ok?
NSAID+ NSAID ok? |
1. yes, neccessary for antiplatelet effect; negates use of COX-2 selective drugs; aspirin should not be used for pain
2. NO RATIONALE FOR USE |
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What if a person has asthma induced by aspirin and needs an NSAID?
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See a specialist; they may be able to tolerate a COX-2 inhibitor; give first dose under medical supervision
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What monitoring is required with NSAIDs?
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CBC - rare blood dyscrasias
CrCl - aggravates RI LFTs - rare hepatitis, aggravates LI *at base line and annually |
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Counselling on NSAIDs
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1. Report symptoms of stomach ulcers (black stools, coffee-colored vomit) or heart failure (swollen ankles, difficulty breathing)
2. Don't use aspirin for pain relief |
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NSAIDs
- General DRUG INTERACTIONS |
1. Aggravating GIT (e.g. prednisolone & BISPHOSPHONATES)
2. Increasing blood pressure 3. Reducing renal function (loops, ACEIs) 4. Reducing renal excretion: Li, Methotrexate 6. Increase nephrotoxicity by reducing RF: Calcineurin inhibitors 5. Increase potassium (e.g. trimethoprim, spirinolactone) 6. Increased fluid retention (TZDs, prostglandin eye drops) 7. Decrease blood clotting |
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Ibuprofen + low dose aspirin
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Interferes with antiplatelet effect. Little knowledge but occassional doses appear ok; avoid if possible or continuous
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NSAID + brimonidine
NSAID eye drops and prostaglandin analogue eye drops |
Indomethacin and probably other NSAIDs negate brimonidine's effect on intraocular pressure - Avoid unless occassional; or use latanoprost
Monitor IOP if using NSAID eye drops long term |
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NSAID + Li
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Avoid unless close monitoring is available. Monitor clinically and with TDM. Low dose aspirin IS SAFE TO USE
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NSAID + MTX
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Unlikely to be significant if MTX dose is <20mg/week
Avoid in antineoplastic doses, but low dose aspirin is safe to use |
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NSASID + TZDs
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Increased risk of fluid retention and heart failure; use cautiously. Low dose aspirin is SAFE TO USE
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NSAIDs+warfarin
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Non selectives are antiplatelet
COX-2 selectives may increase INR If combined, must be monitored clinically and by INR Combination with KETOROLAC is CI Aspirin 2-4g d has direct hypoprothrombinaemic effect |
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What drug interactions apply to aspirin alone?
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1. Decreases BGLs
2. With acetazolamide (carbonic anhydrase inhibitor), increased risk of toxicity such as acidosis 3. Prednisolone may reduce high dose concentrations of aspirin; careful to reduce aspirin dose with reducing prednisolone 4. Increases valproate conc, which is also antiplatelet |
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Probenicid + NSAIDs
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Probenecid reduces excretion of weak acids, including NSAIDs (esp ketorolac and indomethacin)
Aspirin reduces uricosuric (urine excreting) effect of probenecid. Small occasional doses can be used. |
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Important DI with celcoxib & also ibuprofen
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Fluconazole increases celecoxib and ibuprofen concentration
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Bile acid binding resins affect which NSAIDs?
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Parexocib
Sulindac Meloxicam Diclofenac (give 1hr before /4hr after) Also reduces enterohepatic circulation of all except diclofenac, in which case combo is not recommended. |
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When is ketorolac CI?
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1. with a fully anticoagulated person, warfarin, phenindione; with hx of GI ulceration, bleeding disorders, surgery with high bleeding risk
2. with probenecid, with mod-severe renal impairment, hypovolaemia, dehydration 3. allergy 4. Manufacturer CI use with aspirin, li, oxpentifylline |
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Diclofenac
- Explain it's scheduling |
Unscheduled: for dermal use
S2: 12.5mg or less, 20 tablets or less, max 75mg d S3: 25mg or less, 30 or less S4: Everything else |
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Diclofenac
Skin preparations |
1% gel: 20, 50, 100g (Voltaren emugel, Diclac Anti-Inflammatory gel, Imflac Anti-inflammatory gel)
3% gel: Solaraze gel, 25g, 50g |
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Diclofenac
S2 preparations S3 preparations |
S2: Voltaren Rapid 12.5mg.20
S3: 25mg.30 Voltaren Rapid (also x10,x20) Imflac Diclac |
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Diclofenac
S4 preparations |
25mg.50 Enteric Coated tabs
Voltaren, Clonac, Fenac.100, Diclac, Imflac, Dinac, Genrx.100 50mg.20 tabs - Voltaren Rapid 50mg.50 EC tabs - Voltaren, Diclohexal, Genrx, Dinac, Fenac Suppositories: 12.5mg.10, 25mg.10, 50mg.10, 100mg.20 (Voltaren) Arthrotec: 50mg/200mcg misoprostol.60 |
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Diclofenac
- exta indications (2) |
1. actinic keratoses
2. dysfunctional uterine bleeding |
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Diclofenac
- dosing (not Solaraze) - dosing in children |
Oral/ Rectal: 75-150mg d (Max 200mg d) in 2-3 d.d
Children GREATER THAN 6/12: 1-2mg/kg/d (max3mg/kg/d) oral or rectal |
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What PBS restrictions apply to diclofenac?
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1. 25mg.50[100]: PBS-R
2. 50mg.50: PBS-R 3. Only 100mg.20[40] PBS (restriction is to chronic arthropathies) |
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Diclofenac
- Topical use |
1% gel 3-4 times daily
3% gel BD for 60-90 days; A pea-sized amount (0.5g) covers 25cm2; max 8g d |
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Diclofenac
- Acticic Keratoses and Solaraze (a) how effective (b) how long does it take? |
Moderately effective, but lack of comparative data and data on relapse rate
May take up to 30 days after treatment before complete healing & optimal effect |
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Actinic keratoses
- what is that? |
Actinic - relating to the chemically active rays of the EM spectrum
Keratosis - a lesion of the epidermis marked by overgrowth of the "horny layer" (or stratum corneum) actinic keratosis - a lesion on sun exposed areas which can lead to a low-grade squamous cell carcinoma in a minority of patients; "warty" in appearance |
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Celecoxib
- Extra contraindications (2) |
1. Ischaemic heart disease, cerebrovacular disease
2. Allergy to sulphonamides - manufactuer CIs, AMHs cautions |
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Celecoxib
- dosing |
- 200mg d or 100mg bd: Use bd dosing
(a) in R.A. (b) if better patient response: half life is 4-15hr Period Pain: 400mg d/d.d. on first day of period, then 200mg d/d.d. for up to 5 days in total N.B. risk of CV A/Es is dose related, and 200mg d should not be exceeded long term |
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Celecoxib
- Products - PBS-R |
100mg.60, 200mg.30 (Celebrex)
PBS-R: OA and RA |
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Ibuprofen
- Extra indication - Other consideration |
1. Dysfunctional uterine bleeding
2. Aspirin: occassional doses unlikely to have a clinically sig effect. It is unknown if other NSAIDs have this effect |
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Ibuprofen
- Dosing - Children's dosing - Dosing of the gel |
1. 200-400mg tds-qid; max 2400mg d; max 1200mg d on s2/s3
Children FROM 3 MONTHS: 5-10mg/kg 3-4 times daily GEL: FROM 12 YEARS: 4-10cm aa up to qid |
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When do you NOT need to treat a child's fever?
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Children tolerate fevers of 38-38.5 well, and often respond to fluids and comfort, and may not need medications
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Scheduling of Ibuprofen?
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Unscheduled: 200mg.25 or less and not labelled for <6 years
S2: 200mg.100 or less S2: liquids, 4g or less; in manufacturer's original pack S2: in combo with codeine, 10mg.25 or less; of <0.25% codeine (& max 60mg d) S3: 400mg.50 or less and not for children <12 S3: in combo with codeine, no pack limit S4: the rest |
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Ibuprofen
- S3,S4 products - Children's products |
- 400mg.30: Brufen
- 20mg/mL.100/200mL: Nurofen, Bugesic, iProfen - 40mg/mL.30mL: Nurofen for children infant drops |
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Indomethacin
- Extra indication - Extra common S/E |
- Closure of significant patent ductus arteriosus (specialists)
- VERTIGO!! |
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Indomethacin
- Dosing - Products, Brands |
- 25mg.50 capsules (Arthrexin, Indocid)
- 25mg.90 capsules (Arthrexin) - 100mg.20 supp (Indocid) - 1mg/mL.1mL injection (Indocid) TAB: 25-50mg 2-4 times daily (half life up to 6hrs) CHILD: 1-4mg/kg/day SUPP: 100mg bd |
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Indomethacin
- Extra counselling point |
L12!!! (AMH)
"May affect alertness and coordination - avoid driving or operating machinery until you know how you react" |
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Indomethacin
- PBS? |
As for Diclofenac, PBS-R for arthropathies and OA, and suppositories are PBS with 40 supplied
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Ketoprofen
- dose forms, brands |
(1) 200mg.28 CR caps: Orudis SR, Oruvail SR [PBS-R]
(2) 100mg.20 supp (Orudis) [pbs 40] (3) 2.5%.30/60 gel (Orudis) |
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Ketoprofen
- dosing |
200mg d (oral)
100mg at bedtimem (rectal) Topical: aa 2-4 times daily |
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Ketorolac
- dose forms, brands - dosing |
Toradol
- 10mg.20 tab: 10mg up to qid - 10mg & 30mg injections (IM/IV): 10mg stat, then 10-30mg q4-6h, max 90mg d |
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Ketorolac
- indications - TGA approvals - PBS listings |
- Only indicated for post-op pain; switch to oral form ASAP
- Not approved IV in aus (IM is) even though approved in USA and UK - Not PBS listed |
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Ketorolac has many CI: avoid adverse effects by:
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- correcting hypovolaemia before administering
- short term treatment |
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Mefenamic acid
- extra indication - extra common adverse effect |
- dysfunctional uterine bleeding
- DIARRHOEA |
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Mefenamic acid
- scheduling - dosing - dose forms |
- S2: 30 or less FOR THE TREATMENT OF DYSMENORRHOEA
- S4: all the others - 500mg tds - Children: 25mg/kg/d (tds) - 250mg.20 caps Ponstan - 250mg.50 caps Mefic, Ponstan |
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Mefenamic acid
- PBS |
PBS-R: dysmenorrhoea and menorrhagia
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I forgot to mention that diclofenac is also available in an eye drop - what's that called?
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Voltaren Optha
5ml(5mg) bottle 1ml (1mg) single use x30 For post-operative inflammation For prevention of miosis (pupil contraction) during cataract surgery |
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Meloxicam
- dose - indications - PBS - products, brands |
- 7.5-15mg d
- For OA and RA only (similar to celecoxib) - 7.5mg.30, 15mg.30 tabs, caps (Mobic) - Tabs as Mobic, Movalis, Moxicam, Meloxibell - PBS-R for OSTEOARTHRITIS ONLY |
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Parecoxib
- Indication - Contraindication - Consideration |
- Post-op pain
- Increased risk of CV events, major vascular surgery - Manufacturer CI with sulphonamide allergy |
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Parecoxib
- products, brands - doses |
- 40mg IM/IV as a single dose
- 20mg dose if hepatic impairment; or female and >65 or <50kg - Dynastat 40mg injection |
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Piroxicam
- Doses - Products |
- 10mg.50, 20mg.25 dispersable tablet (Feldene-D, Pirohexal-D)
- 10mg.50, 20mg.25 caps (Feldene, Mobilis) - 0.5%.25g/50g gel (Feldene) oral: 10-20mg d as a single dose top: aa tds-qid |
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Piroxicam
- PBS |
PBS-R for chronic arthropathies and OA
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Sulindac
- dose - product, brand - PBS |
200-400mg d or in 2 d.d.
100mg.50 [200]tab 200mg.50 tab Aclin PBS-R for chronic arthrobathies and OA |
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Tiaprofenic acid
- Indications - one extra consideration - Dosing, dose forms |
- RA / OA
- Urinary tract or prostate disease may be exacerbated - 300mg 1-2 times d - 300mg.60, Surgam, PBS-R for chronic arthropathies and OA |
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Naproxen
- Extra indication - Dose equivalence |
- Dysfunctional uterine bleeding
- 550mg naproxen sodium = 500mg naproxen |
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Naproxen
- Scheduling |
S2: 250mg.30 or less
S4: all other preparations |
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Naproxen
- PBS |
250mg.50[100], 500mg.50, 750mg.28, 1000mg.28, 550mg.50: PBS-R for OA and chronic arthropathies
Oral liquid PBS-A for for as above and unable to take tabs |
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Naproxen
- dosing - dosing in children |
250-500mg bd
**(Period pain: 500mg initially, and then 250mg q6-8h, prn) ** (Migraine: 750mg stat, then 250-500mg after at least 1 hour if required) - 750-1000mg SR d - 10-15mg/kg d (in 2 d.d) for juvenile R.A. |
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Naproxen
- S2 Dose forms |
S2:
250mg.30 (Femme-free) 220mg.10/20/30 napNa (Aleve) 275mg.20/24/12 (napNA (Nurolasts, Naproleve, Eazydayz, Chemists Own Period Pain) |
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Naproxen
- S4 dose forms |
250mg.50[100] Inza, Naprosyn
500mg.50 Inza, Naprosyn 550mg.50 Anaprox, Crysanal 750mg.28 Naprosyn SR, Proxen SR 1000mg.28 Naprosyn SR, Proxen SR 25mg/mL.474mL Naprosyn |
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Hylans
- MOA, indication - Contraindications - No cautions - Preg/BF - Adverse effects |
- Increase the lubricant and shock absorbing properties of the synovial fluid or the joint
- Indicated for OA of the knee - Infected or severely inflammed joints, skin infection at site, venous or lymphatic stasis in leg - No data for preg/BF - Transient redness, swelling, pain lasting 3-4 days |
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Hylans
- dose forms, brands - dosing - administration tip - Something important to note about one brand |
- 20mg injection (Fermathron): weekly for 5 weeks
- 16mg injection (Synvisc): weekly for 3 weeks; max 2 courses in 6 months seperated by min 1 month - Synvisc is derived from chicken and absolute freedom from infective agents cannot be guaranteed - Remove effusion if present, before injection |
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Rubefacients
- what is that? - how does it work? - how often do you apply them? - can i use them immediately after injury? - can i use them during pregnancy and breastfeeding? - any other considerations? |
- counter-irritant which produces reddening when applied to skin
- provide a sensation of warmth, which may be comforting in painful musculoskeletal conditions - 2-4 times daily - Yes, but make sure RICE is also used in first 72 hours - AMH says they can be used on small areas during preg/BF - salicylates: allergy to NSAIDs, GI bleeding or HX of, bruising: may worsen |
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Examples of rubefacients and their products
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- Deep Heat (methyl salicylate and menthol)
- Difflam (benzydamine) - Dencorub (a salicylate) - Goanna arthritis cream (a salicylate) - Goanna Heat cream (methyl salicylate, menthol, camphor, eucalyptus oil, pine oil, et.al) Metsal (methyl salicylate etal) Finalgon (nonivamide, butoxyethyl nicotinate) |
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Other topical musculoskeletal agents?
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1. menthol (e.g. Dencorub Arthritis Ice, Ice)
2. Capsaicin (Zostrix 0.025%.45g, Zostrix HP 0.075%.55g) |
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Zostrix
- Extra uses - Side effects |
- Diabetic peripheral neuropathy
- Post-herpetic neuralgia **May cause a stinging and burning sensation |
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All topical musculoskeletal agents should be applied how? (Inc Zostrix)
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2-4 times daily for up to 14 days, then review
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All musculoskeletal agents have the same counselling points, which are? (Including Zostrix)
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Rub in completely to preven staining of clothing
Avoid excess exposure to sunlight on treated areas, as there is a risk of photosensitivity |
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Aspirin
- doses |
- 300-900mg q4-6h (max 3600 d)
- 75-150mg d for antiplatelet effect (150-300mg d may be required in acute conditions) Children Juvenile R.A: 15-20mg/kg q4-6h Kawasaki's disease: 10mg/kg q8h until fever settles; then 3-5mg/kg/d |
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Aspirin: products
(a) low dose (b) analgesic doses on PBS (c) dispersables (d) combinations |
Low dose
- 100mg tab (DBL, Cardiprin) - 100mg EC tab (Cartia) - 100mg EC cap (Atrix) PBS - Solprin - Aspalgin 300mg dispersable tab(Disprin, Aspro, Solprin) 320mg.20 (Aspro) Combination products - with codeine (Aspalgin 300/8) - with pravastatin (40mg/81mg, Pravigard) - with dipyridamole (200/50, Asasantin) |
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Aspirin
- monitoring required with chronic use |
RF
LFTs GI bleeding |
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Aspirin counselling (4)
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Counselling points with aspirin
1. Take with food; disperse immediately before drinking (1/2 a cup), do not remove from packaging until needed 2. Stop 7 days before surgery or some dental procedures (discuss with the relevant doctor/dentist) 3. Stop and report if you experience any (a) swollen ankles (RI) (b) difficulty breathing (bronchospasm) (c) coffee grounds in vomit or black stools (GI bleed) |
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Side effects with aspirin that are different to NSAIDs
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common: tinnitus (high doses), GI bleeds, HEADACHE, dizziness
infrequent: oesopageal ulceration, iron deficiency anaemia, SJS! rare: Reye's syndrome with encephalopathy and severe hepatic injury in children |
