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22 Cards in this Set
- Front
- Back
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List three TNF inhibitors:
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Infliximab
Etanercept Adalimumab |
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When are TNF inhibitors the answer?
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1) Inflammatory bowel disease, particularly Crohn's disease with fistula formation.
2) Rheumatoid arthritis that is not responsive to methotrexate as a disease-modifying drug. 3) Psoriatic arthritis when it is moderate to severe, as an alternative to systemic therapy such as methotrexate or ultraviolet light. 4) Ankylosing spondylitis |
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How do TNF inhibitors work?
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TNF inhibitors are immunosuppressive but less toxic than steroids.
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What are the most common adverse effects of TNF inhibitors?
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TNF inhibitors can reactivate or worsen serious bacterial infections by inhibiting the immune system. TB reactivation in purified protein derivative positive patients is the most important adverse effect. All patients who go on a TNF inhibitor should have a PPD test done first. TNF inhibitors are also associated with developing lymphoma.
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When is methotrexate the answer?
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Methotrexate is the answer to the question "Which of the following is most likely to slow the progression of disease?" in virtually all patients with rheumatoid arthritis. It is clearly the number one disease modifying drug (DMARD) for rheumatoid arthritis. Methotrexate is also indicated for the following conditions:
1) Severe psoriasis, particularly psoriatic arthritis. 2) Leukemia, lymphoma, and certain solid tumors. |
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What are the most common adverse effects of methotrexate?
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1) Liver toxicity
2) Pulmonary fibrosis 3) Bone marrow suppression (myelosuppression) 4) Kidney damage (precipitation of methotrexate crystals) |
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List five DMARDs.
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Hydroxychloroquine
Sulfasalazine Anakinra Abatacept Leflunomide |
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When are DMARDs the answer?
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Alternative DMARDs to methotrexate are the correct answer in the following circumstances.
1) Pt. is intolerant of methotrexate 2) Methotrexate fails to control the disease. 3) Cases of mild disease where its preferable to avoid the toxicity of methortrexate; sulfasalazine and hydroxychloroquine can be used initially in this way. |
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What adverse effects are associated with DMARDs?
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1) Hydroxychloroquine: retinal damage, hemolysis
2) Sulfasalazine: rash, hepatitis, agranulocytosis 3) Anakinra (interleukin-1 antagonist); causes neutropenia 4) Abatacept (inhibits T-cell activation): infections 5) Leflunomide (inhibits pyrimidine synthesis); causes rash, alopecia, myelosuppression, and liver dysfunction. |
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List eight NSAIDS.
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Naproxen
Sulindac Ibuprofen Diclofenac Etodolac Indomethacin Ketorolac Piroxicam |
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List three COX-2 inhibitors.
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Rofecoxib (removed from market)
Celecoxib Valdecoxib (removed from market) |
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For what conditions are NSAIDs and COX-2 inhibitors the best initial therapy?
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NSAIDs and COX-2 inhibitors are indicated predominantly as analgesics. They are also useful for the following conditions:
1) Inflammatory disorders, such as gout, pseudogout, rheumatoid arthritis, and ankylosing spondylitis. 2) Cystic fibrosis 3) Fever 4) Still's disease |
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How do these medications work?
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Both NSAIDs and COX-2 inhibitors inhibit prostaglandins.
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What are their most common adverse effects?
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NSAIDs cause peptic ulcer disease and renal insufficiency, such as interstitial nephritis and nephrotic syndrome. Although COX-2 inhibitors have less effect on the gastric mucosa, they have very severe cardiac toxicity. The COX-2 inhibitors rofecoxib (Vioxx) and valdexoxib were removed from the market because of excess cardiac deaths. Only celecoxib remains on the market.
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A 48 yo man comes to the ED with severe, sudden pain in the left knee and toe after a 'beer binge' over the weekend. On examination, he has a fever. The knee and toe are red and swollen. Joint aspiration shows 25,000 white cells that are predominantly neutrophils, and crystals are present. The crystals are needle-shaped and negatively birefringent. Creatinine is 2.4.
What is the best initial therapy? |
Colchicine is the best initial therapy for acute attacks of gout, particularly when NSAIDs are contraindicated. In this case, a creatinine elevation is a contraindication to NSAIDs. Colchicine is also used to treat familial Mediterranean fever.
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A 48 yo man comes to the ED with severe, sudden pain in the left knee and toe after a 'beer binge' over the weekend. On examination, he has a fever. The knee and toe are red adn swollen. Joint aspiration shows 25,000 white cells that are predominantly neutrophils, and crystals are present. The crystals are needle-shaped and negatively birefringent. Creatinine is 2.4.
How does the treatment work? |
Colchicine inhibits leukocyte mobility, decrease the white cells' ability to phagocytose within the joint space and decrease lactic acid within the joint. This action reduces the deposition of the urate cyrstals that perpetuate the inflammatory response.
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A 48 yo man comes to the ED with severe, sudden pain in the left knee and toe after a 'beer binge' over the weekend. On examination, he has a fever. The knee and toe are red adn swollen. Joint aspiration shows 25,000 white cells that are predominantly neutrophils, and crystals are present. The crystals are needle-shaped and negatively birefringent. Creatinine is 2.4.
What are the most common adverse effects of this treatment? |
The most common adverse effect of colchicine is diarrhea. In fact, you should give colchicine to relieve pain until it produces diarrhea. Rarely, colchicine may produce aplastic anemia.
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A 48 yo man comes to the ED with severe, sudden pain in the left knee and toe after a 'beer binge' over the weekend. On examination, he has a fever. The knee and toe are red adn swollen. Joint aspiration shows 25,000 white cells that are predominantly neutrophils, and crystals are present. The crystals are needle-shaped and negatively birefringent. Creatinine is 2.4.
What therapy would you use if the initial treatment is ineffective? |
If there is no response to colchicine, the next therapy to try is intra-articular steroids.
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What is allopurinol?
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Allopurinol is a drug that lowers urate synthesis and decreases the serum uric acid level.
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How does allopurinol work?
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Allopurinol is a xanthine oxidase inhibitor. This reduces the uric acid level in both blood and urine.
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When is allopurinol the answer?
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Answer allopurinol when the question describes a patient with recurrent gouty attacks, tophi, and uric acid stones and who has failed probenecid or sulfinpyrazone. The patient should be between attacks. Allopurinol has no benefit during an acute attack of gout, because it is not anti-inflammatory.
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What are the most common adverse effects associated with allopurinol?
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Allopurinol is highly allergenic. It can cause rash, eosinophilia, and interstitial nephritis.
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