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32 Cards in this Set
- Front
- Back
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Rheumatoid Arthritis (RA)
Definition |
chronic autoimmune disorder
unknown etiology symmetric, erosive synovitis may extend to extra-articular sites |
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RA
presentation |
- onset - rapid to slow
- course -10-20% short w/remission -70-80% mild to mod w/exacerbations -10-20% progressively destructive - hallmark SX - morning stiffness |
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RA
pathophys |
immune system attack cells in joints causing synovitis (warmth, reddness, swelling, pain)
cells of synovium grow and divide abnormally during inflammatory process causing synovium to become thick |
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RA
Drug Tx |
DMARDs (dz mod anti rheumatic drugs)
NSAIDs Low-Dose oral CS utilize aggressive TX w/DMARDs first is most popular - "inverted pyramid" - w/ or w/out NSAID NSAIDS - should not be considered a sole treatment option |
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RA
DMARDs - The players (list) |
hydroxychloroquine (Plaquenil)
sulfasalazine (Azulfidine) methotrexate (Rheumatrex) gold Na thiomalate (Myochrysine) auranofin (Ridaura) azathioprine (Imuran) penicillamine (Cuprimine) minocycline (Minocin) leflunomide (Arava) etanercept (Enbrel) infliximab (Remicade) anakinra (Kineret) adalimumab (Humira) |
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RA
aspirin and other NSAIDS moa |
prevents prostaglandin formation by inhibiting cyclooxygenase
antithrombotic effect of ASA occurs by irreversible (unique to ASA) inhibition of platelet cyclooxygenase (others reversi) ASA - inflammatory effect 3-5g/day |
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RA
What can be done to avoid complications when pt on chronic NSAIDS? |
dec risk of GI ulceration
- histamine blocker (ranitidine) - PPI - lansoprazole only PPI FDA-appr for prevention of NSAID-induce ulcer -mosoprostol (oral prostaglandin analog) - available in combo with diclofenac (Arthrotec) |
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COX 1 Vs COX 2
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COX 1
- found in most tissues that produce prostaglandins (PGI1 and PGI2 -which protect the gastric barrier) COX 2 - present at sites of inflammation |
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RA
Drug TX - COX 2 inhibitor |
celocoxib - Celebrex
- inhibits prostaglandin syn via COX 2 - black box - CV and GI risk - lower incidence of GI lesions than ibuprofen, naproxen, diclofenac - except when take w/low dose ASA |
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RA
DMARD TX principles |
- reduce or prevent joint damage and
preserve joint integrity and function - initiate DMARD TX w/in 3 months - even if adequate treatment w/NSAID - Methotrexate typical initial tx - track record to induce long respons - DMARDs lose function over time - rare for pt to use one med for > 2 yrs |
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RA
DMARDs - qw or longer doing |
methotrexate (Rheumatrex)
- qw; PO, IM, SC, IV gold Na thiomalate (Myochrysine) - q2-4w; IM etanercept (Enbrel) - qw; SC infliximab (Remicade) - w2,4,6, then q8w; IV adalimumab (Humira) - qow; SC |
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RA
DMARDs- qd to tid dosing |
hydroxychloroquine (Plaquenil)
sulfasalazine (Azulfidine) auranofin (Ridaura) azathioprine (Imuran) penicillamine (Cuprimine) minocycline (Minocin) leflunomide (Arava) anakinra (Kineret) |
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RA
nondrug tx |
Prosorba column - removes inflammatory antibodies from pts blood
Joint surgery mild exercise diet - increase daily protein intake support group |
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Osteoarthritis (OA)
definition |
aka degenerative joint disease (DJD)
affects the weight-bearing joints of the peripheral and axial skeleton 60-80% > 65yo |
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OA
presentation |
-pain worsens w/weight-bearing acty
-changes in weather influence pain -joint/morning stiffness common -different from RA - < 30 min - resolves w/movement -joint deformities - Herberden's and Bouchard's nodes - osteophytes on the DIP and PIP jnts |
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OA
pathophys |
???
affects cartilage (thins) so cant dissipate force of normal weight-bearing acty |
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OA
treatment principles |
-focuses on sx control
-pain relief is primary treatment hip -APAP is first -add NSAID next -then opioid analgesic knee (above plus) - intraocular steroid inj - topical analgesics - capsaicin and methylsalicylates |
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Gout
definition |
systemic dz caoused by build-up of uric acid in the joints
- causes inlammation, swelling, pain - hyperuricemia - > 8mg/dL males >7f |
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Gout
presentation |
-pain in one joint of lower extremity
-initial period of pain self-limiting - then period w/no SX -intercritical periods (times b/w attacks) - 3m to 2y - shortens as dz progresses -knee, ankle, heel, wrist, finger, elbow -may experience fever chills mailaise -untreated lasts 1=2 weeks |
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Gout
pathophys |
primary gout
- uric acid overproducers - uric acid underexcreters acute gout attacks caused by deposition of monoNa urate crystals (MSU) in the synovium of the joint - results in stim of inflam cascade - sharp crystals damage leukocytes - causes them to spew contents - results in inflammatory reaction |
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Gout
treatment goals |
-relieve pain and inflammation
- reduce serum uric acid - prevent recurrent attacks |
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Gout
Drug TX - three treatments for acute attacks |
1. colchicine
2. NSIDs (indomethacin mainly) 3. CSs |
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Gout
colchicine |
-colchicine
-anti-inflam but no analgesic atcy - inhibits leukocytes from gulping up urate crystals -never exceed 8mg during acute attack -0.6 to 1.2mg po q2h until - pain relief achieved - or diarrhea ocurs - works best if start w/in 12-36h of onset of attack |
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gout
indomethicin |
is effective at any point during an attack
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gout
corticosteroids |
given intra-articularly, IV or PO
limited to treatment failure w/colchicine and NSAIDs |
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Gout
prophylaxis |
low dose colchicine (0.6-1.2mg/d)
treatment depends on whether pt is an overproduce or underexcreter excrete > 600 = overproducer |
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Gout
prophylaxis - underexcreters |
uricosurics
- probenecid (Benemid) - sulfinpyrazone (Anturane) - promote excretion of uric acid - drink > 2L/water/d to dec uric acid stone formation - never begin uricosuric tx during attack - since uricosuric tx may precipitate an attack - take cholchisine or NSAIDs for first 6-12 months |
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Gout
prophylaxis - over producers |
xanthine oxidase inhibotor
- xanthine a precursoer in uric acid syn - allopurinol (Zyloprim) - immediately report any rash - qd dosing |
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NSAIDs
acetic acids |
diclofenac (Voltaren, XR) qd-bid
etodolac (Lodine, XL) qd-bid indomethacin (Incodin, SR) qd-bid nabumetone (Relafen) qd-bid tolmetin (Tolectin) sulindac (Clinoril) |
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which NSAIDs can be taken by route other than PO?
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diclofenac (Vlotaren) PO, Ophth
indomethacin (Indocin) PO, IV, supp |
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NSAIDs
propionic acids |
fenoprofen (Nalfon)
flubiprofen (Ansaid) ibuprofen (Motrin) ketoprofen (Orudis, SR) - QD naproxen (Naproxyn) oxaprozin (Daypro) - QD |
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NSAIDs
others |
fenamates
meclofenamate (Meclomen) oxicams piroxicam (Feldene) - QD cox-2 selective celocoxib (Celebrex) |
