Anti-inflammatory 3

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Neda317
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231414
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Anti-inflammatory 3
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2013-09-12 06:15:46
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Anti-inflammatory 3
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  1. Rheumatoid Arthritis signs
    • Systemic Inflammatory disease F> M
    • Symmetrical arthritis
    • Synovium first
    • bones get thinner
  2. Rheumatoid Arthritis
    affected area
    • Extra-articular involvement Joints
    • Joints- Eyes - Heart - Lungs
  3. Rheumatoid Arthritis
    Diagnosis:
    • History of Early morning stiffness for 1 hour or longer
    • Simultaneous swelling of 3 or more joints for
    • longer than 6 weeks
    • Wrist, PIP not DIP
    • Elbow,
    • ankle and knee
    • Rheumatoid nodules
  4. Rheumatoid Arthritis
    need to order
    • Order
    • ESR to follow disease activation
    • Always
    • order joint X-ray
  5. Rheumatoid Arthritis
    RX first
    • Always
    • answers NSAIDs First or COX2 inhibitors
      If not O.K. within 3 Months Go to DMARDS (Disease-Modifying Antirheumatic Drugs)
  6. name 8 Disease-Modifying
    Antirheumatic
    Drugs
    • 1. Methotrexate (rheumatrax)
    • 2. Hydroxychloroquine
    • 3. Sulfasalazine
    • 4.Corticosteroids
    • 5. Gold salts
    • 6.D-Penicillamine
    • 7. Cyclophosphamide
    • 8.Azathioprine
  7. Methotrexate MOA:
    • Inhibits Dihydrofolate reductase
    • Cytotoxic to lymphocytes
  8. Methotrexate Adverse effects
    • Bone marrow suppression
    • Hair loss, mucositis
    • Worsens Nodules
  9. MOA

    Hydroxychloroquine
    Stabilizes lysosomes and decrease chemotaxis
  10. Adverse effect
    Hydroxychloroquine
    • 1. Cinchonism: GI distress and visual dysfunction
    • 2. Hemolysis in G6PD deficiency
  11. MOA
    Sulfasalazine
    like ASA inhibits COX2

    Sulfapyridine: decrease B cell functions
  12. Adverse effect
    Sulfasalazine
    • ASA: GI distress
    • Sulfapyridine: Rash, hemolysis, sysytemis lupus erythmatos (SLE) like syndrome
  13. MOA
    Corticosteroids
    decrease LTs, IL2, and PAF
  14. Adverse effect
    Corticosteroids
    • ACTH depression
    • Susceptibility to infections
  15. MOA
    Gold salts
    decrease lysosomal and macrophages functions
  16. Adverse effect
    Gold salts
    • Stomatitis, rash, bone marrow depression
    • Proteinuria and nephrotic syndrome
  17. MOA
    D-Penicillamine
    • Suppress
    • T-cell and decreased Rheumatoid factor
  18. Adverse effect
    D-Penicillamine
    Aplastic anemia, myasthenia gravis
  19. MOA
    Cyclophosphamide
    Alkylating agents used in severe cases
  20. Adverse effect
    Cyclophosphamide
    hemoregic(Hgic) cystitis
  21. Side effects: 

    Azathioprine
    Bone marrow suppression
  22. MOA
    Azathioprine
    • Immunossuppresive in autoimmune disease
    • Inhibits purine synthesis
  23. side effect
    Azathioprine
    Bone marrow suppression
  24. TX for Willson's disease
    D-Penicillamine
  25. New
    FDA DMARDs 5
    biologics
    • 1.Infliximab (Remiceid???)
    • 2.Etanercept (Enbrel)
    • 3.Leflunomide
    • 4.Anakinra
    • 5.Adalimumab (Humira)
  26. Infliximab
    adverse effect
    • Infusion
    • reactions, infections
  27. Infliximab
    Monoclonal antibody
  28. Etanercept (Enbrel)
    A recombinant of TNF receptor --> Binds to TNF
  29. Etanercept (Enbrel)
    adverse effect
    • Hypersensitivity,
    • infections
  30. Leflunomide
    adverse effect
    • Alopecia,
    • rash, hepatotoxicity
  31. Leflunomide
    MOA
    • Pyrimidine synthesis inhibitor
    • Inhibits dihydro-orotic acid dehydrogenase -> dec. UMP -> dec. RNA
  32. Anakinra
    MOA
    IL-1 receptor antagonist
  33. Anakinra
    adverse effect
    Reaction at injection site, infection
  34. Adalimumab (Humira)
    treatment of
    • Recombinant
    • Monoclonal antibodies
    • binds to TNF
  35. Adalimumab (Humira) 
    MOA
    Binds to TNF
  36. Most common from of arthritis M=F
    Osteoarthritis
  37. Osteoarthritis
    characteristic
    • Cartilage disruption
    • New bone formation = osteophytes
    • Increase with age
    • Weight bearing joints
    • Stiffness less than 30 minutes in the the
    • morning
  38. Osteoarthritis Primary
    most common
    2ry Osteoarthritis: Anything that affects cartilages --> joint deformity
  39. Osteoarthritis Diagnosis:
    • X-ray
    • Unequal loss of joint space
  40. Osteoarthritis
    RX
    • Exercise
    • Weight loss
    • Medications: Acetaminophen, Ibuprofen, COX-2 inhibitor, celecoxib.
  41. This is not an inflammatory disease
    It
    is a bacterial infection
    Osteomyelitis
  42. Osteomyelitis
    what bacteria will cause
    Staph aureus
  43. Osteomyelitis
    Any part of the bone: marrow, cortex and periosteum
  44. Osteomyelitis
    in children & Adult
    • C: Acute
    • A: chronic
  45. A 52 y/old male, DM, ulcer on tibia X 4 weeks
    Draining tract, no fever
    Next
    best step
    X-Ray
  46. if X-ray +
    then
    biopsy and rx IV antibiotic
  47. If X-ray is -
    then
    • bone scan or MRI
    • if + --> biopsy --> IV antibiotic 
    • if - --> no osteomyletis --> Rx is ulcer
  48. Why
    diagnosis of bone involvement is necessary before Rx
    You don't wanna put someone on IV antibiotics For 6 weeks without a diagnosis of osteomyelitis
  49. For
    Staph aureus:
    RX is
    Ox/Clox/Diclox and Naf
  50. Widespread
    aching and stiffness for longer than 3 months
    Fibromyalgia
  51. Fibromyalgia's lab work
    Normal
  52. Fibromyalgia what to look for
    • Look
    • for Tender points
    • Short sleeve shirt part
    • shoulder, trapezius and hip girdle
  53. Fibromyalgia
    Rx
    • Analgesics and antidepressants
    • cymbalta (duloxetine)
  54. cymbalta (duloxetine) treatment for
    • diabetic neuropathy and 
    • chronic pain
  55. pregabalin (lyrica)
    tx for
    Fibromyalgia
  56. Polymyalgia Rheumatica
    • Elderly with same presentation as Fibromyalgia
    • except Lab: Increased ESR
  57. Polymyalgia Rheumatica 
    diagnosis
    Giant Temporal Arteritis (Biopsy)
  58. Polymyalgia Rheumatica
    tx
    • Give steroids 15 mg/day and taper --> Come
    • back with severe headache--> Increase
    • steroids to 40mg/day --> If
    • you don't they go blind
  59. Crystal induced Arthritis Male 10:1
    Gout
  60. Gout
    • Big Toe
    • Elevated serum Uric acid
  61. Gout why
    • Increased UA production: Idiopathic
    • Decreased UA excretion (Renal)
  62. Gout 
    lab
  63. Negative birefringence with polarized light
  64. Drugs
    used for Gout
    • NSAIDs first
    • Indomethacin
    • Naproxen and sulindac
  65. Acute
    Gouty Attack:
    what drug?
    Colchicine
  66. MOA
    Colchicine
    • MOA:
    • Binds to tubulin--> dec. microtubular
    • polymerization -->Decrease formation of LTB4
    • Inhibits
    • leukocyte and granulocyte migration
  67. Adverse effects 
    Colchicine
    • Acute:
    • Diarrhea and GI pain
    • Long
    • term: Mylosuppression,
    • peripheral neuropathy
    • hematuria
    • and alopecia
  68. Chronic gouty arthritis
    • Goal
    • is to decrease uric acid
    • 1.Allopurinol
    • 2.Probenicid
    • 3.Sulfinpyrazone
  69. MOA 1.Allopurinol
    inhibits xanthine oxidase -> dec. purine metabolism -> dec. uric acid
  70. Adverse effect
    • Peripheral
    • neuropathy, stone formation
    • rash,
    • vasculitis
    • Inhibits 6-mercaptopurine metabolism
    • Must
    • lower the dose of 6-MP (cancer drug)
  71. MOA
    2.Probenicid
    • Inhibits proximal tubular reabsorption of urate, inhibits
    • secretion of acidic drugs: Penicillins
  72. Probenicid 
    adverse effect
    • high excreter of urate -> urate
    • crystals in the kidney
  73. MOA
    3.Sulfinpyrazone
    similar to Probenicid
  74. adverse effect
    3.Sulfinpyrazone
    • GI distress, rash, nephrotic
    • syndrome
  75. Sulfinpyrazone activity
    • is GFR dependent (not good below 30ml/min)
    • Inhibits
    • platelet aggregation
  76. Corticosteroids 
    MOA at cellular level
    4
    • 1.Inhibit the release of inflammatory mediators
    • 2.Decrease migration of leukocytes
    • 3.Decrease capillary permeability
    • 4.Decrease phagocytosis by stabilizing lysosomalmembrane
  77. Corticosteroids MOA
    at the biochemical level
    4
    • 1.Inhibits phospholipase A2
    • 2.Block COX2 expression
    • 3.Decrease platelet activating factor
    • 4.Decrease interleukins (IL-2)
  78. Corticosteroids 
    Adverse effect
    8
    • 1.Electrolyte imbalance: edema, HTN
    • 2.Increase infection and decrease wound healing
    • 3.Hyperglycemia due to gluconeogenesis
    • 4.Osteoporosis
    • 5.ACTH suppression: cortical atrophy
    • 6.Iatrogenic Cushing's syndrome
    • 7.Increase glaucoma & Cataracts
    • 8.Steroid rage (mental dysfunction)

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