Endo treatment summaries Flashcards

Question

RHEUMATOID ARTHRITIS

Answer 1

PARACETAMOL +/- WEAK OPIOIDS - For analgesia with no anti-inflammatory effect NSAIDS/COX-2 INHIBITORS - Reliefs joint pain and stiffness but do not slow disease progression - Full analgesic effect within a week while anti-inflammatory effect within 3 weeks - Only use selective COX-2 inhibitors in patients with high risk of GI ulceration and bleeding (assess cardiovascular risk) - Lowest effective dose prescribed for a short period CORTICOSTEROIDS - Exhibit rapid anti-inflammatory effect - Large doses can supress disease progression (long term risk/toxicity) - Can be given with DMARD or bridging before DMARD shows any effect - Used for RA flares - Increase the risk of osteoporosis (consider prophylaxis if treatment is long term) - Methylprednisolone (1g max) for 3 days used to suppress active inflammation - Prednisolone 7.5mg od used to reduce joint destruction in moderate-severe RA of less than 2 years onset - Given as intra-articular injections (hydrocortisone acetate injections are often used for no more than 4 times/year for each inflamed joint) DMARDS - Used within 3-6 months of onset to prevent irreversible joint damage (max effect seen within 6 months) - They reduce ESR, C-RP & rheumatoid factor levels to prevent further disease manifestations SULFASALAZINE (can be taken during pregnancy) - Used for mild-moderate RA full response in 8-12 weeks - Initial dose is 500mg od then titrated up to 2-3 g od (divided doses) at 1-week intervals - Monitor FBC initially and monthly during first 3 months and monitor LFTS every month for the first 3 months - The patient must report any unexplained bleeding, bruising, sore throat or fever and stop immediately if there is blood dyscrasia METHOTREXATE 1st line (not given if pregnant) - Used for moderate-severe RA and effect seen after 6-8 weeks - 7.5mg (3x 2.5mg tablets) once a week max 20mg weekly - Monitor FBC, renal and liver functions - Folic acid 5mg every week co-administered the day after MTX tablet to reduce side effects - Avoid using aspirin and NSAIDS - The patient must report sore throat, bruising and mouth ulcers (signs of blood disorders) - The patient must report nausea, vomiting, abdominal discomfort and dark urine (signs of liver toxicity) - The patient should report shortness of breath (sign of respiratory problems) HYDROXYCHLOROQUINE - Lowest efficacy and causes ocular toxicity/retinopathy - Used for mild RA or in combination with other DMARDs - Monitor FBC, urea, electrolytes, LFTs and eye sight AZATHIOPRINE - Used for severe RA. Monitor FBC - Report GI problems GOLD (NOT USED ANYMORE) - Sodium aurothiomalate IM injections used for progressive disease but have severe ADRs - Auranofin also has many ADRs and has low efficacy PENICILLAMINE similar to gold but is better tolerated - Low efficacy and hardly used CICLOSPORIN used for severe active RA when other agents are inappropriate CYCLOPHOSPHAMIDE used for RA with severe manifestations but is toxic and regular blood tests should be carried out LEFLUNOMIDE - Rapid onset of action effect starts after 4-6 weeks - Same efficacy as MTX and sulfasalazine (can be used if they are not tolerated/contraindicated) - Need a procedure to wash out (metabolite stays for a long time) if there are severe ADRs or before starting another agent or before conception - Patients require effective contraception during treatment and for at least 2 years after in women (at least 3 months after in men) BIOLOGICALS – CYTOKINE INHIBITORS a) TNF-alpha inhibitors: adalimumab, certolizumab pegol, etanercept, golimumab and infliximab b) IL-6 inhibitors: tocilizumab and sarilumab c) IL-1 inhibitors: anakinra d) T cell deactivator: abatacept e) Causes B cell lysis: rituximab - Adalimumab, etanercept +/- MTX and infliximab + MTX for active RA in adults whose disease has responded inadequately to intensive therapy with 2 cDMARDs DAS28 3.2 – 5.1 with commercial arrangement to lower price - Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept, sarilumab + MTX for active RA in adults whose disease has responded inadequately to intensive therapy with 2 cDMARDs DAS28 > 5.1 - Rituximab + MTX if other TNF-alpha inhibitors did not work DAS28 > 5.1 - Assess response after 6 months using EULAR before continuation - Certolizumab pegol, Abatacept, golimumab, tocilizumab, Sarilumab - the manufacturers provide as agreed in the patient access schemes (PAS). JANUS KINASE INHIBITORS (JAK) - Inhibit tyrosine kinase: baricitinib, tofacitinib, upadacitinib and filgotinib - Upadacitinib or Filgotinib +/- methotrexate for active RA in adults whose disease has responded inadequately to intensive therapy with 2 cDMARDs DAS28 3.2 – 5.1 with commercial arrangement to lower price - Filgotinib, Upadacitinib, Tofacitinib, Baricitinib, or Sarilumab, Adalimumab, etanercept, infliximab and abatacept, Certolizumab pegol or Tocilizumab MTX for active RA in adults whose disease has responded inadequately to intensive therapy with 2 cDMARDs DAS28 > 5.1 with commercial arrangement to lower price - Anakinra + MTX in controlled long-term clinical studies - Assess response after 6 months using EULAR before continuation SURGERY Joint replacement and arthroplasty PHYSIOTHERAPY STEP WISE APPROACH 1) Monotherapy with conventional DMARD MTX, leflunomide, hydroxychloroquine or sulfasalazine +/- corticosteroid bridging 2) Combination of 2 DMARDs or change DMARD +/- corticosteroid bridging 3) cDMARD + biological DMARD 4) cDMARD + JAK inhibitor

Answer 2

ACUTE ATTACKS: - NSAIDS: 50-100mg indomethacin od gradually reduced to 25mg tds over 5-7 days as attack subsides (used for 7-14 days) - COLCHICINE: 1mg initially then 500mcg max qds (max 6 mg per course and not repeated within days) the dose is reduced for elderly/renally impaired patients - CORTICOSTEROIDS: if 1 or few joints inflamed joints, oral/IM methyl-prednisolone 4-10mg for small joints and 20-80mg for bigger ones - MONOCLONAL ANTIBODIES: canakinumab only used for frequent attacks (min 3 in 12 months) or if other treatments not tolerated/effective LONG TERM MANAGEMENT AT LEAST 2 WEEKS AFTEER ATTACK WITH 3 MONTHS PROPHYLAXIS - ALLOPURINOL: initially 100mg od after food, can be increased up to 900mg (300mg tds) according to urate levels Dose reduced in renal failure. Ensure adequate fluid intake. Prophylactic NSAID/colchicine co-administered for at least 1 month to avoid future attacks (after correcting urate levels). Can cause rash (exfoliative dermatitis), if it occurs withdraw and reintroduce and if it happens again stop immediately - FEBUXOSTAT: 80mg od and 120mg od can be given if urate above 6mg/100ml 2-4 weeks following treatment Given if allopurinol is not tolerated or contraindicated Stop immediately if hypersensitivity or anaphylaxis occurs - URICOSURIC: SULPHINPYRAZONE 100-200mg od with food initially increasing to 600mg od over 2-3 weeks and continued until urate level is normal (then educe gradually to 200mg od) Avoid aspirin and salicylates when taking it Contraindicated in renal failure (risk of urate crystals) and uric acid stones history Not given within 3 weeks of acute attack Prophylactic NSAID/colchicine co-administered for at least 1 month to avoid future attacks (after correcting urate levels). - Special orders of probenecid (to prevent nephrotoxicity) and benzbromarone (for mild renal impairment) are also available - Rasburicase is licensed for chemotherapy induced acute hyperuricaemia LIFESTYLE CHANGES - Weight reduction - Lower alcohol consumption - Lower purine intake - Increase water intake - Adjust dose/stop inducing drugs (thiazide diuretics and aspirin

Answer 3

LIFESTYLE CHANGES - Weight reduction - Hot press on affected joint - Physiotherapy to preserve joint function - Hydrotherapy/ swimming - Suitable footwear - TENS machine PHARMACOLOGICAL MANAGEMENT 1- PARACETAMOL 1 g qds max regularly for 2 weeks (trial) 2- TOPICAL NSAIDS 3- ORAL NSAIDS Start with ½ max dose and increase according to need Diclofenac max 150mg od, ibuprofen max 2.4 g od or naproxen max 1g od For acute inflammation but avoid if the patient is older than 65, smoker, takes anticoagulants/antiplatelets or has a history of GI problems Avoid alcohol to prevent kidney injury 4- OPIOIDS 5- INTRA-ARTICULAR CORTICOSTEROIDS 6- CHONDROPROTECTIVE AGENTS Chondroitin, glucosamine and vitamin E Hyaluronic acid and its derivatives for the knee (injected into synovial fluid) 7- SURGERY IF ALL TREATMENTS FAIL

Answer 4

ERYTHROPOIESIS STIMULATING AGENTS - Increase RBC production - IV (during dialysis) or SC - Epoetin alpha, beta, theta or zeta and methoxy polyethylene glycol-epoetin beta - Monitor haemoglobin levels, blood pressure, RBC and beware of seizures and allergic reactions - Increases risk of stroke and VTE and pure red cell aplasia IRON - Oral or IV supplement given to reach target of 200-500mcg/L - Examples are iron sucrose and iron dextran - Higher iron level (up to 700) reduces ESA requirement, blood transfusion and mortality risk

Answer 5

VITAMIN D SUPPLEMENTS - Cholecalciferol (inactive form) or calcitriol (active form) can be given with calcium - If calcium level is normal then pulse dosing (3 times a week) is used - If calcium level is low than 0.25-1mcg od (max 5mcg od) - Monitor phosphate and calcium level CALCIMIMETICS CINACALCET - reduces PTH release only licensed in dialysis patients but used in stage 4 CKD or post-transplant - Monitor calcium level within 1 week of initiation and after dose changes, PTH level during the day, PTH level 12 hours post dose when PTH peaks then every 2-4 weeks - Taken with food (in the evening) to increase bioavailability and reduce N&V ETELCALCETIDE - Given 3 times a week IV on dialysis days - Initially 5mg (range 2.5-15mg) - Used when cinacalcet not tolerated or contraindicated - Monitor calcium and PTH levels PHOSPHATE BINDERS - Bind to phosphate forming insoluble compounds that are excreted. Taken with meals. - Available as tablets, chewable tablets and sachets - Include calcium acetate, magnesium and lanthanum cations - Also include sevelamer, sucroferric oxyhydroxide (colours stool) and aluminium binders - Sevelamer and calcium acetate most commonly used - Cause GI side effects and reduce the absorption of levothyroxine, doxycycline and ciprofloxacin PARATHYROIDECTOMY - Indicated in calciphylaxis, pathological fractures, severe hypercalcaemia and hyperphosphatemia (PTH >85) - Can be total or subtotal - The patient is given calcium and active vitamin D post surgery DIETARY RESTRICTION - Avoid food that is high in phosphate and triggers parathyroid hormone increase

Answer 6

SODIUM THIOSULFATE IV - During dialysis sessions to increase calcium solubility - Avoid calcium and vitamin D products

Answer 7

WHO PAIN LADDER 1- Paracetamol +/- NSAID 2- Paracetamol +/- NSAID + weak opioid (dihydrocodeine, tramadol, paracetamol combinations or codeine) 3- Paracetamol +/- NSAID + a strong opioid (morphine, diamorphine or fentanyl) TRAMADOL - Weak opioid so less constipation and respiratory depression but can cause convulsions (serotonin syndrome) - Tramacet (paracetamol+ tramadol) stronger than paracetamol but weaker than paracetamol MORPHINE - 5-10mg every 4 hours for normal release or every 12 hours for modified release initially (20-30mg daily or 40-60mg if switched from another opioid) can go up to 200mg every 4 hours or 600mg every 12 hours in severe pain - If converting to SC/IM, give half oral dose - For breakthrough pain, give 1/10 – 1/6 total daily dose or the same as the regular dose if recently initiated (not more than 1/3 – 1/2 total. Daily dose) DIAMORPHINE - Usually given SC/IM/IV - To convert from morphine to diamorphine, divide by 3 (1/3 morphine dose) - For breakthrough pain, give 1/10 – 1/6 daily total dose - To convert from diamorphine to oral (MR) morphine, multiply total daily diamorphine dose by 2 (if pain is stable) or by 3 (if the pain is too much) FENTANYL - If switching from MR morphine, apply fentanyl patch after last morphine dose - 30mg morphine per day = ‘12’ fentanyl patch for 72 hours - Give 1/6 equivalent daily morphine dose for breakthrough pain - If switching to another opioid, the initial dose should be low and gradually increased BUPRENORPHINE - Used in step 2 - If the patient is opioid naïve, then 35mcg/h patch for 4 days (moderate to severe pain) - Full effect after 24 hours usually assessed after 72 hours - For breakthrough pain, give 200-400mcg sublingually - Maximum 2 patches to be worn at the same time - Wait for 24 hours before administering another opioid (t1/2 is 30 hours) - Available strengths are 5, 10 and 20 patches for 7 days • For opioid induced nausea & vomiting, give metoclopramide 10mg tds or haloperidol 1.5mg om • Usually, 2 laxatives are used while the patient is on opioids (senna and Dulcolax)

Endo treatment summaries Flashcards

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