The Musculoskeletal System (Pharm Made Easy 3.0)

Front 1

Drugs that treat Rheumatoid arthritis

Back 1

•Nonsteroidal anti-inflammatory drugs (NSAIDs)

•Glucocorticoid

•Disease modifying anti-rheumatic (DMARDs)

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Disease-Modifying Anti-Rheumatic drugs (DMARDs)

Back 2

•DMARDs decrease joint inflammation, joint damage

Front 3

Categories of DMARDs

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•DMARDs 1: major non-biological

•DMARDs 2: major biological

•DMARDs 3: minor non-biologic and biologic

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DMARDs 1 (major non-biologic)

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•Treat: anti-metabolite drugs that interfere with normal metabolic process and suppress immune response, treat cancer in larger doses and slow or stop progression of rheumatoid arthritis

•Examples:

-Methotrexate (pregnancy category X)

-Leflunomide (pregnancy category X)

•Side effects:

-Liver damage (monitor liver function: AST & ALT; also monitor for yellowing of skin + eyes = jaundice) ☆

-Bone marrow suppression ☆

-Increased risk for infections

-G.I ulceration (monitor for G.I bleeding like dark tarry stools and coffee ground emesis)

-Pulmonary fibrosis (report difficulty breathing & shortness of breath)

•Instruct patients to drink 8 to 12 8 oz of glasses daily

•Avoid INGESTING alcohol while on this drug

•Do NOT give to patients with liver insufficiency

•Do NOT give to patients with hepatitis

•Do NOT give to patients with renal insufficiency

•Do NOT give to patients who are pregnant

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DMARDs 2 (major biologic)

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•Treat: Anti-inflammatory effects

•Examples:

-Infliximab

-Adalimumab

-Etanercept

•These drugs are called tumor necrosis factor antagonist, which prevent inflammatory reaction in joints

•Side effects:

-Susceptibility to infections increases

-Severe skin reactions (Steven Johnson syndrome, toxic epidermal necrolysis, erythema multiforme; monitor for skin reactions right after administration)

-Heart failure (monitor for cough, shortness of breath, elevated BP, HR and pink sputum)

-Reactivation of latent tuberculosis (make sure to give a TB test to patient on this med)

•Avoid unnecessary immunizations!

•Do NOT give to patients with active infections

•Do NOT give to patients with hematologic disease

•Do NOT give to patients with malignancy (cancer)

•Do NOT give to patients on this drug LIVE VACCINES

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DMARDs 3 (minor non-biologic and biologic)

Back 6

•Obsolete (are not used to treat rheumatoid arthritis anymore; unless there is a severe case of rheumatoid arthritis)

Front 7

Drugs to treat Osteoporosis

Back 7

•Selective Estrogen Receptor Modulator (SERMs)

•Biphosphonates

•Calcitonin

•Calcium supplements

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Selective Estrogen Receptor Modulators (SERMs)

Back 8

•Treat: prevention and treatment of postmenopausal osteoporosis & reduces risk of estrogen dependent or receptor positive breast cancer

•Examples:

-Raloxifene (less risk of uterine cancer)

-Tamoxifen

•Activate estrogen receptors in the endometrial tissues and bones, which decreases bone absorption & decreases bone loss; it also blocks access to estrogen receptors in breast tissue (this reduces the likelihood of breast cancer)

•Side effects:

-Increases risk of pulmonary embolism (PE) & deep vein thrombosis (DVT) (monitor for dyspnea, chest pain, drop in O2 saturation as well as pain & redness of the leg calf)

-Hot flashes

-Risk pregnancy category X (female patient require contraception while on this med)

•Do NOT give to pregnant women

•Do NOT give to breastfeeding moms

•Do NOT give to patients with a current or history of DVT

Front 9

Biphosphonates

Back 9

•Treat: presentation and treatment of postmenopausal osteoporosis in women, aged related osteoporosis in men and glucocorticoid related osteoporosis

•Examples:

-Alendronate

-Risedronate

-Ibandronate

•DECREASES bone absorption by DECREASING the number and action of osteoclasts

•Side effects

-Esophagitis ☆

-G.I disturbance (nausea, vomiting, abdominal pain)

-Muscle and joint pain (notify provider to obtain pain control) ☆

-Eye pain and visual changes

•Make sure patient takes meds 30 minutes before breakfast (full glass of water) ☆

•For 30 minutes AFTER administration ☆

-Place patient in a sitting or standing position

-Instruct the patient to not eat or drink anything beside water for those 30 minutes after administration

•Instruct patient NOT to take calcium supplements or antacids 30 minutes after administration of BISPHOSPHONATE

•Do NOT give to patients with esophageal strictures or dysphagia (difficulty swallowing)

•Do NOT give to patients unable to sit or stand for 30 minutes after administration

•Do NOT give to patients with renal insufficiency

•Do NOT give to patients with HYPOcalcemia

Front 10

Calcitonin

Back 10

•Treat: treatment of postmenopausal osteoporosis, HYPERcalcemia secondary to hyperparathyrodism and paget’s disease

•Example:

-Calcitonin-salmon (ONLY; given I.M, S.C & intranasally)

•DECREASES bone reabsorption, INHIBITS action of osteoclasts, INCREASES excretion of calcium and decreases serum calcium in patients with HYPERcalcemia

•Side effects

HYPERSENSITIVITY reactions and ANAPHYLAXIS in patients with fish allergies ☆

-HYPOcalcemia (provide diet high in calcium and vitamin D)

-Nasal dryness and irritation (intranasal form; assess nostrils before administration of intranasal calcitonin-salmon)

DECREASE in therapeutic effects over time ☆

•BEFORE administering calcitonin-salmon perform an intra-dermal allergy test for fish allergy

Front 11

Calcium supplements

Back 11

•Treats: HYPOcalcemia, used for patient at risk for calcium deficiency (adolescents, pregnant women, breastfeeding, post menopausal and men & women at risk for osteoporosis) and treats gastric hyperacidity

•Examples:

-Calcium citrate

-Calcium carbonate (Tums)

•Provides non-dietary source of calcium, neutralizes gastric acid in the stomach, combine vitamin D and calcium supplement to increase absorption in intestines

•Side effects

-HYPERcalcemia (nausea, vomiting, constipation, polyuria and depression)

-Kidney stones (monitor for flank pain or blood in the urine)

•Give CALCIUM SUPPLEMENTS 1 hour before or 2 hours after administration of

-Glucocorticoid

-Thyroid supplements

-Tetracycline and quinolone antibiotics

•Give CALCIUM based ANTACIDS 1 hour after meals and at bedtime (full glass of water)

•To PREVENT constipation increase fluid & foods high in fiber; give laxatives as needed

•Do NOT give to patients with HYPERcalcemia

•Do NOT give to patients with HYPOphosphatemia

•Do NOT give to patients with kidney stone

•Do NOT give to patients with cardiac dysrhythmias

Front 12

Cholinesterase inhibitors

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•Treats: improves muscle strength & endurance

•Examples:

-Neostigmine

-Pyridostigmine

-Edrophonium (used to DIAGNOSE myasthenia gravis) ☆

•Prolong action of acetylcholine by INHIBITING acetylcholinesterase and allow STRONGER & LONGER muscle contractions

•Side effects:

◇ High level of cholinesterase inhibitors

-Increased intestinal motility

-Increased salivation

-Bradycardia (notify provider if apical pulse is less than 60 beats per min) ☆

-Muscle weakness and respiratory paralysis (within 1 hour of administration/administer ATROPINE to correct this muscle weakness)

◇ Low level of cholinesterase inhibitors

-Muscle weakness and respiratory paralysis (within 1 hour of administration/administer ATROPINE to correct this muscle weakness)

•Assess for TOXICITY (EXCESSIVE salivation + EXCESSIVE diarrhea)

•Eat meals 45 minutes to an 1 hour after taking cholinesterase inhibitor

•Take drug on strict schedule (same time, every day)

•Do not give to patients with mechanical obstruction of bowel or urinary tract

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Neuromuscular blocking agents

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•Treat: INHIBIT muscle contraction, PROMOTE muscle relaxation during anesthesia, control seizures, suppress spontaneous respirations and gag reflex in patients who are intubated

•Examples:

-Succinylcholine (depolarizing)

-Pancuronium (non-depolarizing)

•BLOCK action of acetylcholine at neuromuscular junction

-Depolarizing agents: prevent repolarization of muscle tissue

-Non-depolarizing agents: prevent muscle contraction

•Side effects:

-Postoperative muscle pain

-HYPERkalemia ☆

-HYPOtension (Give an antihistamine to prevent further hypotension) ☆

-Bradycardia and cardiac arrest ☆

-Respiratory arrest

-Malignant hyperthermia ☆

•Explain to patient that paralysis is temporary while on a neuromuscular blocking agent

•Do NOT give to patients at RISK for HYPERkalemia (major burns, trauma, electrolyte imbalances)