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Pharmacology of Arthritis and Osteoporosis Treatments, Exams of Nursing

A comprehensive overview of the pharmacological management of arthritis and osteoporosis. It covers the characteristics, symptoms, and treatment goals for different types of arthritis, including rheumatoid arthritis and osteoarthritis. The document also delves into the mechanisms of action, medications, and precautionary considerations for various disease-modifying antirheumatic drugs (dmards) used in the treatment of rheumatoid arthritis. Additionally, it explores the management of gout, including the use of nsaids, corticosteroids, and urate-lowering therapies. The document then shifts its focus to osteoporosis, discussing the treatment goals, medication options (bisphosphonates, denosumab, and estrogen agonist/antagonists), and the associated patient education and monitoring requirements. This extensive coverage of arthritis and osteoporosis pharmacology makes this document a valuable resource for healthcare professionals and students interested in these areas of study.

Typology: Exams

2023/2024

Available from 07/29/2024

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NR 565 Pharmacology Week 4 questions with

answers

Most common inflammatory form of arthritis - ANSWER: ➡ Gout Characteristics: RA - ANSWER: ➡ Rapid onset 3:1 in women/men Age 35-50 years at onset Affects hands and feet local and systemic inflammation 60 mins morning joint stiffness Symmetric Elevated ESR Leukocytosis Systemic symptoms RA symptoms - ANSWER: ➡ Pain Swelling Warmth Stiffness Characteristics: Osteoarthritis - ANSWER: ➡ Slow onset (years) 1:1 in men/women Age > 50 years at onset Affects hands, hips, knees Mild or local inflammation < 30 min morning joint stiffness symmetric or asymmetric pattern

ESR normal Mild leukocytosis No systemic symptoms Symptoms: Osteoarthritis - ANSWER: ➡ Pain Bone enlargement Treatment goals: RA - ANSWER: ➡ Relieve symptoms Maintain joint function and ROM Decrease systemic involvement Delay disease progression Medications: RA - ANSWER: ➡ NSAIDS Glucocorticoids Conventional DMARDS Biologic DMARDS Mechanism of action: Conventional DMARDs - ANSWER: ➡ Immunosuppressant Inhibits dihydrofolate reductase Inhibits lymphocyte proliferation Folate antagonist Mechanism of action: Bioloic DMARDs - ANSWER: ➡ Inhibits JAK 1,2,3 = disruption of cytokine and growth factor signaling pathways Mechanism of action: Targeted DMARDs - ANSWER: ➡ Binds to and inhibits tumor necrosis factor alpha = decreased inflammation and altered immune response Medications: Conventional DMARDs - ANSWER: ➡ Methotrexate Sulfasalazine (azulfidine)

Leflunomide (arava) Hydroxychloroquine (plaquenil) Medications: Biologic DMARDs - ANSWER: ➡ Adalimumab (Humira) Certolizumab pegol (cimzia) Etanercept (Enbrel) Golimumab (Simponi) Medications: Targeted DMARDs - ANSWER: ➡ Tofacitinib Baricitinib DMARD prescribing considerations - ANSWER: ➡ Obtain baseline CBC w/WBC differential Assess for s/s of infection (TB/hepatitis) and malignancies R/O pregnancy Assess risk for immunocompetence (liver/renal status) Comprehensive H+P to establish baseline Screen for TB Baseline diagnostic data: Conventional DMARDs - ANSWER: ➡ ALT, AST, serum creatinine Baseline diagnostic data: Methotrexate - ANSWER: ➡ Chest x-ray, pulmonary + GI status Baseline diagnostic data: Sulfasalazine - ANSWER: ➡ Chest x-ray, pulmonary + neurological status Baseline diagnostic data: Hydroxychloroquine - ANSWER: ➡ Ophthalmic exam, cardiac exam w/ ECG

Baseline diagnostic data: Leflunomide - ANSWER: ➡ Chest x-ray, BP + pulmonary status Gout - ANSWER: ➡ Common type of inflammatory arthritis Increased uric acid levels in the blood Deposits in joints and surrounding tissues in the form of crystals Complications of untreated gout - ANSWER: ➡ Erosion and irreversible joint damage, renal damage, and tophi ACP recommendations for Gout - ANSWER: ➡ 1. Corticosteroids, NSAIDs, or colchicine for acute gout

  1. Low-dose colchicine for acute gout
  2. Avoid long-term urate-lowering therapy after 1st gout attack or in patients with infrequent attacks
  3. Discuss benefits, harms, cost, and preferences before initiating urate-lowering therapy Medications for Gout: NSAIDs - ANSWER: ➡ Naproxen Ibuprofen Dicolfenac Meloxicam Indomethacin Celcoxib Medications for Gout: Corticosteroids - ANSWER: ➡ Intra-articular injection Use when NSAIDs are contraindicated Medications for Gout: Oral/systemic - ANSWER: ➡ Colchicine *Use for acute treatment

Medications for Gout: Chronic treatment - ANSWER: ➡ Allopurinol (drug of choice in renal dysfunction) Febuxostat Mechanism of action: Cochicine - ANSWER: ➡ Exact mechanism unknown Mechanism of action: Allopurinol and Febuxostat - ANSWER: ➡ Inhibits xanthine oxidase Precautionary considerations: Colchicine - ANSWER: ➡ Renal/hepatic impairment, biliary obstruction Elderly or debilitated patients Precautionary considerations: Allopurinol - ANSWER: ➡ Caution in African-American, asian, or Hawaiian/Pacific Islander patients Caution in renal/hepatic impairment Precautionary considerations: Febuxostat - ANSWER: ➡ Caution in severe hepatic impairment or CVD Side effects: Colchicine - ANSWER: ➡ N/V/D Cramping Abd. pain Fatigue Headache Pharyngolaryngeal pain Side effects: Allopurinol - ANSWER: ➡ Rash D/N Pruritus Urticaria

Sonmolence Increased ALT/AST Eosinophilia Side effects: Febuxostat - ANSWER: ➡ Increased LFTs Gout exacerbation Labs: Colchicine - ANSWER: ➡ CrCL at baseline CBC for long-term use Labs: Allopurinol - ANSWER: ➡ BUN, CrCL at baseline and periodically with renal infection or disease LFTs with hepatic disease Labs: Febuxostat - ANSWER: ➡ LFTs at baseline Allopurinol hypersensitivity syndrome - ANSWER: ➡ Severe, can be life threatening Rash, fever, liver dysfunction, renal dysfunction Stop allopurinol, seek medical attention Don't take antihistamines Adverse reactions: Colchicine - ANSWER: ➡ Rhabdomyolysis Increased risk in patients who take statins Discuss potential risk of muscle injury Mechanism of action: Urate-lowering drugs/xanthine oxidase inhibitors - ANSWER: ➡ Treat underlying cause of gout flare-ups Initial Febuxostat therapy - ANSWER: ➡ Decrease production of uric acid = prevent gout attacks In the beginning, symptoms may flare

Colchicine or NSAIDs are given for up to 6 months to prevent flares Uricosuric agents - ANSWER: ➡ Probenecid Benzbromarone Sulfinpyrazone Lesinurad Probenecid - ANSWER: ➡ Used for chronic gout Can exacerbate acute episodes Delay treatment until acute attack subsides Allopurinol and Warfarin - ANSWER: ➡ Allopurinol may delay metabolism of warfarin Warfarin dose should be decreased when allopurinol is added Osteoporosis - ANSWER: ➡ Decreased bone mineral density and bone mass Changes in quality or structure of bones Increased risk of osteoporotic fractures Osteoporosis treatment goals - ANSWER: ➡ Slow or stop bone loss Prevent fractures Osteoporosis: Postmenopausal women - ANSWER: ➡ Inadequate intake of dietary calcium Requires supplementation Osteoporosis: CPGs - ANSWER: ➡ Men and PM women > 50 should be considered for treatment if: Hip or vertebral fracture T-score of -2.5 or less @ femoral neck or spine Low bone mass

Medication therapy: Osteoporosis - ANSWER: ➡ Bisphosphonates Denosumab (RANKL inhibitor) Raloxifene Medications for osteoporosis: Bisphosphonates - ANSWER: ➡ Alendronate Ibandronate Zoledronic acid Bisphosphonate treatment rank - ANSWER: ➡ 1st line for PM women with prior hip or vertebral fracture DXA T-score of -2.5 or less Mechanism of action: Bisphosphonates - ANSWER: ➡ Inhibits osteoclast activity = decreased bone resorption Mediations for osteoporosis: Denosumab (RANKL Inhibitor) - ANSWER: ➡ Prolia Xgeva Denosumab (RANKL Inhibitor) treatment rank - ANSWER: ➡ Alternative initial treatment for PM women with osteoporosis and increased risk of fractures Mechanism of action: Denosumab (RANKL Inhibitor) - ANSWER: ➡ Binds to RANKL > decreased osteoclast formation, maintenance and survival = decreased bone resorption Medications for osteoporosis: Estrogen agonist/antagonists - ANSWER: ➡ Evista Raloxifene Estrogen agonist/antagonist treatment rank - ANSWER: ➡ Treatment and prevention of osteoporosis in PM women who have contraindications to bisphosphonates and denosumab

Mechanism of action: Estrogen agonist/antagonists - ANSWER: ➡ Selectively binds to estrogen receptors = estrogenic/ anti-estrogenic effects Patient education: Bisphosphonates - ANSWER: ➡ Wake with full glass of water Remain upright for 30-60 mins (risk of esophagitis) Food prevents absorption Don't eat for 30-60 mins after taking medication Patient education: Denosumab - ANSWER: ➡ Take 1000mg of Ca++ and 400iu of Vit. D daily Increased immunosuppression Good dental hygeine Increased risk of fracture when medication is d/c Patient education: Reloxifene - ANSWER: ➡ Adequate intake of Ca++ and Vit. D D/C 72 hours before prolonged immobilization Increased risk of DVT, PE, and thrombotic stroke *Black box warning: venous thromboembolic events in PM women with history of or increased risk of CHD Therapeutic goals: Bisphosphonates - ANSWER: ➡ Prevent and treat osteoporosis Increase bone density and prevent bone loss Therapeutic goals: Denosumab - ANSWER: ➡ Prevent fracture Increase bone density Prevent bone injury in patients with metastatic bone lesions Hypercalcemia of malignancy > maintain Ca++ levels Therapeutic goals: Raloxifene - ANSWER: ➡ Prevention and treatment of PM osteoporosis

Decrease risk of invasive breast cancer in PM women with osteoporosis or those at increased risk for beast ca Baseline data: Bisphosphonates - ANSWER: ➡ Axial DXA + height Serum ca++ and vit. d Creatinine level/renal function Pregnancy test Baseline data: Denosumab - ANSWER: ➡ DXA + height Oral exam Baseline ca++ and vit. d Pregnancy test Baseline data: Raloxifene - ANSWER: ➡ DXA + height Baseline ca++ and vit. d Mammogram Pregnancy test Monitoring: Bisphosphonates - ANSWER: ➡ DXA every 1-2 years until stable Periodic ca++, vit. d and creatinine Monitoring: Denosumab - ANSWER: ➡ DXA every 1-2 years until stable Check height annually Monitor for increased back pain-spinal x-ray to check for vertebral fracture Check ca++, creatinine, magnesium within first 2 weeks Monitoring: Raloxifene - ANSWER: ➡ DXA every 1-2 years until stable Check height annually Monitor for increased back pain-spinal x-ray to check for vertebral fracture Check weight periodically

Yearly mammograms High-risk patients: Bisphosphonates - ANSWER: ➡ Esophageal/swallowing disorders Creatinine < 30-35ml/min Correct decreased ca++ and vit. d before initiating therapy IV form contraindicated in ARF or CrCL <35ml/min High-risk patients: Denosumab - ANSWER: ➡ Patients with immunodeficiencies Correct ca++ before initiating therapy Caution in decreased ca++, renal function, PTH/thyroid surgery, or malabsorption syndromes High-risk patients: Raloxifene - ANSWER: ➡ Pregnancy History of venous thrombotic events