What is RA
Chronic systemic inflammatory disease affecting joint synovial membrane
RA symptoms
Pain and stiffness - worse with rest, inactivity, and heat in joints. Nodules, swelling, tenderness, malaise, fatigue, fever, weight loss
RA non-drug therapy
physio, exercise, relaxation, stress management
RA drug therapy
1: MTX, leflunomide or sulfasalazine (hydroxychloroquine in mild)
2: MoAbs (adalimumab, entanercept, infliximab, tocilizumab, baricitinib)
- bridge with corticosteroids when rapid suppression needed
- NSAIDs for pain relief
RA drug therapy interaction
MTX and NSAID not ok OTC - ok if rxed
MTX MHRA Warnings
- Once a week
- Prescription and label clearly shows dose and frequency
- Commonly co-rxed with folic acid, not on MTX day
- Report signs of blood dyscrasia, liver toxicity and respiratory effects
MTX side effects
- Blood dyscrasias - sore throat, bruising, mouth ulcers
- Liver toxicity - N&V, abdo discomfort, dark urine, jaundice, itchy skin
- Pulmonary toxicity - SOB, coughing
- GI toxicity - stomatitis, diarrhoea
MTX toxicity antidote
Folinic acid (calcium folinate)
MTX monitoring and screening
- FBC, UEs, LFTs - every 1-2 wks until stable, then every 2-3 months
- Rule out pregnancy - MTX is antifolate so harmful to foetus growth
- Contraception during and after tx for men and women
MTX Interactions
- Nephrotoxics - MTX reduces renal function
- NSAIDs - not ok OTC
- Other antifolates - trimethoprim, phenytoin, co-trimox
- Hepatotoxics - rifampicin, antifungals
- Omeprazole/Esomeprazole - reduces clearance so increases toxicity
What is Gout
Increase in uric acid = deposition of crystals in joints and other tissue from increased salt intake, chemo drugs and bendroflumethiazide
Gout Acute Tx
- High dose NSAID (not aspirin) + PPI
- Colchicine 500mcg 2-4 x day, max 3 days, no repeats within 3 days
Alternative: short course corticosteroid or IM injection of corticosteroid or canakinumab
Gout Chronic Tx
- 2 or more attacks a year
- reduce uric acid with xanthine-oxidase inhibitors
1. Allopurinol
2. Febuxostat
-If acute attack during tx, continue chronic tx and tx acute separately
Allopurinol side effects
When initiation, use colchicine/NSAID to prevent flare
- Rash - stop, if mild - restart carefully but stop if recurrence
Allopurinol interaction
Allopurinol increases dose of azathioprine/mercaptopurine - reduce dose of aza/merc
Nocturnal Leg Cramps Treatment
- Quinine sulphate - trial of 4 wks, if benefit - continue
- Potential toxicity so only use if cramps regularly disrupt sleep, are very painful, or other tx hasn’t worked
- Stop tx every 3 months and assess need for further tx
NSAIDs Indication
Pain related to inflammation e.g. RA, back pain, soft tissue disorder
NSAIDs contra-indication
Asthmatics due to bronchospasms
NSAIDs GI side effects most to least risk
- Piroxicam, ketoprofen, ketorolac
- Indometacin, diclofenac, naproxen
- Ibuprofen
- Cox-2 selective inhibitors (Celecoxib, Etoricoxib)
NSAIDs CV side effects most to least risk
- Cox-2 selective inhibitors (Celecoxib, Etoricoxib), Ibuprofen 2.4g, Diclofenac
- medium - none
- Naproxen, Ibuprofen 1.2g
- Lowest - none
NSAIDs considerations
- NSAIDs + aspirin/alcohol = increase GI bleed risk
- Use PPI - stomach protection
- avoid in renal impairment - risk of fluid retention and further impairment
- avoid in pregnancy - caution in breastfeeding
NSAIDs Interactions
- MTX/Lithium - reduces clearance
- Ciprofloxacin - increase risk of seizures
- Blood thinners - increase risk of bleeding
- Hyperkalaemic drug - Hyperkalaemia
- Nephrotoxics (DAMN) - AKI
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MSK22
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Eyes4
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Ears4
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Nose4
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Skin26
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Vaccines18
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Anaesthesia8
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Blood and Nutrition72
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Genitourinary40
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Contraception38
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Respiratory69
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Immune System and Malignant Disease49
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Gastrointestinal97
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Endocrine139
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Infection162
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Cardiovascular130
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Central Nervous System173
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OTC122
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Law163
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POM to P21
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Miscellaneous18
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Description Qs48
