Shelbye's CSON Notes Blog



Rheumatoid ArthritisRandomsAutoimmune inflammatory disorder3x more in women than menUsually appears in 3rd or 4th decadeCan become really debilitating, quite painfulCan do surgery to try and pin fingers and correct it, but is not the first choice of treatmentJoints become swollen, tender, and warmIf you can stop the inflammatory process you can slow the destruction of the jointsRA tider is test looking for antibodies specific to RAIn the joints we have synovial fluid which lubricates it, keeps it moving smoothly. This is effected by RA and caused painSystemic effects like fever, weakness, fatigue, weight loss, thinning of skin, scleritis (inflammation in the sclera), corneal ulceration, vasculitis. If people have vasculitis there is probably something autoimmune-wise in their bodyOsteoarthritis should not be confused with this. No systemic effects, kind of a natural part of ageingPathoSymmetric joint stiffness, pain, more intense in the morningJoints become swollen, tender, and warmSystemiceye, pulmonary disease, pericarditis fatigue, anorexia, weaknessOverview of TherapyRelieve symptomsPain, inflammation, and stiffnessAlso lifestyle modification (physical therapy, exercise, surgery for joints if they need it, may remove diseased synovium), can do tendon repair if tendons are affected, can use plastic implants for these guysMaintain joint function and range of motionManage systemic involvementDelay disease progressionThis is a main goal with progressive diseases. Keep them from getting to the end stages as long as we canAntiarthritic DrugsNon-steroidal anti-inflammatory (NSAIDs)Provide symptomatic relief but do not slow progression. They are efficient, have a rapid onset, and are relitively inexpensive. Both analgesic and anti-inflammatory actionsGlucocorticoids (adrenal corticosteroids)Very potent anti-inflammatory agents. May be able to slow progression of disease (as well as relieve symptoms). Can be given systemically or injected into specific joints. Always use these guys short term if possible because they cause adrenal atrophy, set us up for infection, osteoporosis, and hyperglycemia (cause they increase blood glucose levels). Most common are prednisone and prednisolone used for RA. If the pt has a fungal infection, they won’t be treated with these because it will worsen the fungal infection. Always increase dose when the body is under stress. Disease-modifying antirheumatic drugs (DMARDs)Reduce joint destruction and they slow disease progression. Usually when the process is acute these meds will be started within a few months of the diagnosis. They take several months to be effective (that’s why we start giving them early. Don’t use in acute process, considered for chronic and prophylactic use). Monitor clients closely b/c they are considered toxicCyclooxygenaseCox-1: Housekeeper (goes to all tissues)Inhibition of Cox-1 can cause Gastric erosion and ulcerationBleeding tendenciesRenal impairmentCan reduce platelet aggregation when you’re on a Cox 1 inhibitor (good for cardiac people, like when we give them aspirin)Cox-2 (goes to the tissue that is impaired)Inhibition of Cox-2 is mostly beneficialSuppression of inflammationAlleviation of painReduction of feverSupports renal function (important to watch renal failure people if we give them a Cox 2 inhibitor)NSAIDsFirst Generation Prototype: naproxen (Naprosyn)Adverse Effects: GI disturbances, renal function compromise, increase risk of MI and stroke, bleeding time prolongationContraindications: PUD, bleeding dyscrasias Be careful in hemorrhagic stroke people (don’t want to cause more bleeding)Watch when taking with any other antiplatelet Dosage: 250-500 mg twice dailySecond Generation Prototype: celecoxib (Celebrex)MOA: selectively inhibits COX-2 (can also inhibit Cox 1 but if it’s within therapeutic range it’s only Cox 2)Adverse Effects: dyspepsia, abdominal pain, risk of cardiovascular eventContraindications: heart disease, CABG surgery, caution in dyslipidemia, HTN, DM, renal impairment, sulfonamide allergy, pregnancy Dosage: 100-200 mg twice a dayThese are reserved to people with GI bleeds and any one who can’t tolerate a first generation NSAIDWill relieve joint pain, stiffness, and inflammation.Does contain a sulfa molecule (need to know if people are allergic to sulfa) Can mess with fetal heart, so any preggers shouldn’t take this med.DMARDs IPrototype: methotrexate (Rheumatrex, Trexall, others)MOA: inhibits dihydrofolate reductase and lymphocyte proliferationAdverse Effects: blood dyscrasias (occur because this drug causes bone marrow supression, ex thrombocytopenia, leukopenia, neutropenia), hepatotoxicity, nephrotoxicity Contraindications: pregnancy (causes fetal demise), liver diseaseDosage: 7.5-25 mg PO/IM every weekFor long term RA DMARD 1 is the first choiceHas a low cost. Therapeutic affects will occur in 3-5 weeks. DMARD 1 is the fastest of all the DMARDsWhen seen in oncology you’ll see much higher doses. They’re trying to stop the body from destroying itself in this caseThis med blocks the synthesis of folic acid which inhibits the replication of rapidly dividing cellsMost concered with liver disease people and renal disease people, starting with renal insufficiencyCan cause GI ulceration and if it does cause this they are going to stop the medication. Dr. can order a PPI or H2 agent (like pepsid) for these guys to prevent this from happening. Used prophylactically they have a better outcome when treating these. Also take these guys with a full glass of water to prevent GI distressHepatotoxicity = jaundice, fatigue, dark urine, anorexia, itchy skin, ascites. If we see these then we know the person is in troubleMake sure to give women of child bearing age taking this med 2 forms of birth control. Also, we have to give them a pregnancy test before starting them on this medMonitor LFT’s, renal function, CBC, plateletsClient should report anorexia, abdominal fullness, jaundiceTake with food or full glass of waterMay require prophylactic use of PPIAvoid use during pregnancyUse adequate contraception during pregnancyPrototype: hydroxychloroquine (Plaquenil)MOA: Inhibits rheumatoid factor, acute phase reactants, and many enzymesGood for the milder symptoms, sometimes they combine this with the methotrexate. Plaquenil alone won’t stop disease progression. Sometimes it’s used for joint pain/stiffness that occurs with LupusHas a late onset and is often combined with an NSAID or steroid (so they don’t feel shitty until the drug starts working)Adverse Effects: retinal damageMake sure and monitor their visual acuity. Tell them to go to an eye dr. to get checked out, report any s/s of visual changes, even if it’s just a little bit of blurring, whatever. The sooner you get on that the better…If retinopathy sets in it can be permanent and can cause blindnessRisk of retinal damage increases as the dose increases. The higher the dose the higher the risk. If they complain of blurred vision, you should tell them to stop taking the med immediatelyContraindication: retinal or visual field changes, pregnancy Dosage: 200 mg bid or 400 mg once dailyPrototype: sulfasalazine (Azulfidine)MOA: Exact MOA unknown (but they theroise that it affects 5-aminosalacylic acid (5-ASA)Reduced inflammation by suppressing prostaglandin synthesis and it also suppresses migration of the inflammatory cells that go to the affected area. As it’s name indicates, anyone with a sulfa allergy should not take this medication (or if you have an aspirin allergy don’t take it)Adverse Effects: GI, anorexia, diarrhea, hepatitis, bone marrow suppression Don’t give to people who are already immunosuppressed shouldn’t have these medsCan cause macrocytic and hemolytic anemias Contraindications: sulfa and salicylate allergiesDosage: 2 g/day in divided dosesEnteric-coated preparations in divided daily doses help diminish GI symptomsMonitor liver function tests, CBC, and platelet countsTell them to tell us if they have any kind of GI irritation going onDMARDs IIInfoImmunosuppressive agentsTarget specific components of inflammatory processKind of a newer therapyFour currently availableEtanercept (Enbrel)Infliximab (Remicade)These first two cause injection site irritation (main AE)May complain of redness, itching, or redness at the site. If this occurs the meds should be stopped. Adalimumab (Humira)Anakinra (Kineret)These meds are biologic agents and are also listed as tumor necrosis blockers.These meds pose an increased risk for infection and if you start seeing any s/s of infection (fever, chills, sore throat, etc.) tell someone…DMARDs IIIPrototype: lefunomide (Arava)MOA: inhibits T-cell proliferationAdverse Effects: hepatotoxicity, severe HTN, respiratory infection, diarrheaContraindications: pregnancy, severe infection, concurrent live vaccinationDosage: 10-20 mg/dayThese guys can inhibit the metabolism of NSAIDs. This will cause toxicity (we look at liver if this happens).DMARDs IVPrototype: Gold Salts (has been around since the 1930’s)Gold can relieve pain and stiffnessMOA: exact MOA unknown, suppresses synovitis (the inflammatory process/irritaion that happens in the synovial fluid)May arrest the progression of the joint degeneration, but probably not as effective as other agentsAdverse Effects: intense pruritus (most common), stomatitis, renal toxicity, blood dyscrasias (monitor CBC, WBC), hepatitis, GI stuff (N/V and abd pain)Contraindications: heavy metal toxicity (serious)They save this treatment for those people who don’t respond or are unable to take any of the other DMARDsTake 4-6 months to have a therapeutic responseHow do we know if our kidneys are being affected negatively by these guys? We’ll see some proteinurea. If we see any of these toxicities this medication must be stopped Might see bleeding and bruising in the gums if they have dyscrasia. Teach to use soft tooth brush and don’t shaveStop medication and call primary care provider if intense pruritus, rashes, or mouth ulcerations developMonitor I & O, BUN, creatinine, and UAMonitor CBC, WBC, and platelet countObserve for signs of bruising and bleeding of gumsMonitor LFT’sGoutInfoProblem with uric acid metabolismHallmark is hyperuricemia Characterized by Defective purine (found in foods) metabolismattacks of acute pain, swelling, tenderness of joints (big toe, most common site)tophi – deposits of uric acid or urates (crystalized). These crystals will increase in size and you see them most often along the edge of the ear. Caused by an accumulation of uric acid that increases the production/ or inhibits the excretion of uric acidWhen you’re having an attack of gout the uric acid level in the blood is elevated along with the tophi Purine FoodsLow Purine FoodsGreen veggies and tomatoes, fruit and fruit juices, breads that do not use yeast (unlevined breads, kosher crap), nuts, milk and milk products such as butter and cheese, chocolate, coffee and teaHigh Purine FoodsAlcohol, meats (beef, pork, bacon, lamb), seafood (scallops), anything with a specific amount of wheat in it, like beer and breads and what not. Asparagus, cauliflower, mushrooms, peas, spinach, whole grain breads and cereals, white poultry meats (chicken, turkey, duck), and also kidney and lima beans. Risk Factors for GoutObesityHypertensionLead exposureDrugsthiazides, aspirin, alcohol, cyclosporineThese increase your risk for gout, can interfere with uric acid excretion. If you have a patient with hyperuricemia and their on one of these agents they’ll be on gout medicationDrugs that Increase Uric AcidACE inhibitorsAlcohol (and turkey and ham at thanksgiving and Christmas are prime times for flare ups)Aminoglycosides (gentomycin)DiureticsCancer chemotherapy agentsDrug TherapyPrototype: Colchicine MOA: decreases leukocyte lactic acid production and phagocytosis of urate crystals resulting in ↓ uric acid deposition and ↓ inflammatory responseSpecifially treats the inflammation that occurs with gout. Take this in an acute phase, if you’re having symptoms you take this. It’s an alkaloid derivative. Metabolized by P450 so it can accumulate with no inhibitor (like grapefruit juice). Teach patient to not take this with grapefruit juice. The “azoles” will also cause this to accumulate. Dose of 0.6 mg for prophylaxis (3 times a day?)Dose of 0.6 mg every one to two hours during an acute attackAdverse Effects: nausea, vomiting, abdominal Pain, diarrheaIf the AE’s are really severe the medication should be stopped. To decrease the effects of GI crap you take the medication with food. Contraindications: hepatic & renal impairment, severe GI tract disordersCan cause fetal harm, careful when giving to preggers This slows the metabolism of Coumadin increasing the risk of hemorrhage when taken togetherProbenecid (Benuryl)Sulfonomide derivitive Increases urinary excretion of uric acid, and will lower serum uric acid levelsCan prevent or resolve those urate deposits (that cause those tophi bitches in your ear/elbow)Take with foodCourse of therapy not to be repeated within 3 days; very narrow margin of safetyNo alcohol & avoid high purine foodsAlkalinize the urineEncourage intake of 2-3 liters of fluids dailyStop medication is severe GI symptoms occurYou take it at the first sign of the attack, but as soon as you start having relief of symptoms you stop taking the drug. Need to notify dr at the first signs of N/V/D, sore throat. This is telling you that you maxed out your dose and you’re going to have toxicity, you need to get ahold of you dr Prototype: allopurinol (Zyloprim) (used for prophylaxis tx of Gout)MOA: inhibits xanthine oxidase, interfering with conversion of hypoxanthine and xanthine to uric acid. Will decrease uric acid in urine and serum. Helps to prevent attacks, but does not relieve acute episodes of gout.Xanthine is an enzyme required to form uric acidAdverse effects: Skin rash, bone marrow suppression, hepatotoxicity, renal failureContraindications: caution in impaired renal and/or liver functionConcerned most with old people, we’ll see that all of a sudden this older person has thrombocytopenia. It was the allopurinol causing this, not cancer…Dosage: 100-200 mg bid or tid or 300 mg once dailyNo alcoholIncrease fluids (water and fruit juices are good)Maintain a diet that enhances alkalinity of urine Alkaline urine puts you at risk for UTI’s, esp old people. This is the only kind of stone/crystal or whatever that needs alkaline peeNotify for side effectsHave uric acid levels checkedMonitor PT/INR and report symptoms of bleeding if on CoumadinSlows the metabolism of Coumadin, monitor PT, INR if they are on coumadin. May require a dose change ................
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