Drug Classifications & Examples Dosing & Considerations

Anti-Gout or Uricosic Agents Xanthine Oxidase

Xanthine Oxidase - used to inhibit inflammation, prevent synthesis of uric acid and must not disrupt the biosynthesis of vital
- Allopurinol purines
- Febuxostat - ADR- Hypersensitivity rash (higher in blacks/hispanics)
- Allopurinol can be used for renal impairment
Cholchicine
Cholchicine
- impacts granulocytes reducing deposit of uric formulation
Probenecid, Pegloticase, and Lesinurad - Anti-inflammatory & pain medication
- Mostly used as prophylactic or during acute attack
- ADRs: myopathy, weakness, neuropathy and malabsorption of B12
* all not used in pregnancy & in children
(except of uricemia of malignancy) Probenecid, Pegloticase, and Lesinurad
* Can precipitate renal stones - impacts uric acid excretion or change it into inert substances thus reducing deposits and deposition retarded.
* ADRs: GI disturbances and peptic ulcer - Probenecid is sulfa based & only used in pregnancy.
- Drug of choice for older adults.
Arthritis Acetaminophen
- Acetaminophen - 1st ordered drug; overuse or sudden change in activity can created inflammatory response requiring NSAIDs.
- NSAIDs - Can be used for up-to moderate pain
- Glucosamine Therapy NSAIDs
- Arthritis Steroid injection - Lowest dose for pain relief is best
- Non-steroid injection - Topical NSAIDs (votary 1%) is safer than oral therapy and benefits of being applied to region of high
discomfort. Less GI effects
Glucosamine Therapy
- takes months for full effects
- Has an anti-inflammatory and touted as safer than NSAIDs
Arthritis Steroid Injections
- used in conjunction for physical therapy, oral medications, weight loss and overall gradual activity increases.
- Injections to joint increase risk for osteomyelitis.
- Four injections per year.
Non-steroid injections
- Hyalurone and other viscous solutions are intended to supplement synovial fluid in larger joints
- Not endorsed by major specialities societies.

 Drug Classifications & Examples Dosing & Considerations

Rheumatoid Arthritis DMARDs

- Aggressive movement toward use of - Nonbiological: Methotrexate
disease modifying antirheumatic drugs - Methotrexate
(DMARDs) creates the best long-term - Inhibits cytokine activity and purine production
outcomes - Take 6 weeks for full effects
- Smoking increase risk and progression - Can be mixed with other DMARDs
- Contraceptive use for longer than 7 years - Pregnancy Category X
be “protective” for a few years. - ADRs: GI distress, Stomatitis, Folic acid deficiency, Photodermatitis,
- First line- DMARDs - Monitoring
- Kidney
- Liver
- Platelet
- Education
- Wash urine-contaminated clothing separately
- Hydrochlorquine (Plaquenil)
- Doesn’t cause bone marrow suppression like others in the group
- Significant corneal deposits and retinal degeneration (Requires yearly eye examination & self-
monitoring with amsler grid for more frequent monitoring)
- Used for malaria before newer drugs
- Minocycline
- Tetracycline family of medication
- Best used in mild, early disease
- ADRs: photodermatitis
- Never used in pregnancy
- Janus Kinase Inhibitor
- Used for moderate-sever RA
- Prefer over parenteral biologicals
- Helps with bone erosion
- May not decrease synovitis
- Increase risk for infections
- Biological (Not started until failure of non-biologicals and progression to moderate-severe RA)
- Strong immunosuppressive properties. Increase risk for infections, cancers, site reactions
- There are 2 types:
- TNF-alpha inhibitor (Etanercept, infliximab, adalimumab)
- Non-Alpha TNF inhibitor (abatacept, rituximab)
- Remember patient cannot receive any active/live vaccination.
- ADRs: Steven-johnson, renal compromise, and progressive multifocal leukoencaphalopathy
- Bio-similar- same clinical endpoints as the biologics. Not generic versions. Can only be used for same FDA
approved indications.

 Drug Classifications & Examples Dosing & Considerations

Osteoporosis Selective Estrogen Receptor Modulator (Raloxifene (Evista))

- Diagnosed when bone density is 2.5 SD - Have estrogenic effects on bone
below average - Protective against breast cancer
- Increased at risk for fractures especially Biphosphonates (Alendronate (Fosomax), Risedronate (Actonel))
at areas of stress. - Reduce bone resorption by inhibiting osteoclast activity —> increasing bone density
- Medications that increase risk for - No longer used for preventative therapy
osteoporosis - First line therapy for postmenopausal women with osteoporosis
- Glucocorticoids- 5 mg/day > 3 months - First line therapy for men older than age 70 years with osteoporosis
- Anticonvulsant - Instruct patient to remain upright after taking medication for 30 minutes with a full glass of water.
- LT PPI - ADR: Esophageal/Gastric Upset, Hyoocalcemia, Hypophospatemia, CV: A-Fib, arthralgia, myalgia,
- Heavy tobacco or alcohol use headache, Pathological fractures & Osteonecrosis of jaw
- Aromatase inhibitor - Caution: renal impairment, Heart failure, liver disease and active GI problems
- Treatment - Drug interaction: Ranitidine- increase bioavailability
- Selective estrogen receptor modulator Calcium & Vitamin D
- Biphosphonates - Prevents and treat osteoporosis
- Calcium & Vitamin D - Include low-impact bone-strengthening exercise
- Estrogen Estrogen
- Low dose maintain bone mineral density
Monitoring
- Measure Bone Mineral Density
- 10% loss = double the fracture risk
- DEXA is gold standard
- Baseline evaluation for all women older than 65 y.o
Education
- Role of diet, caffeine, alcohol and smoking on risk for developing osteoporosis
- Importance of adequate calcium and vitamin D intake regardless of treatment.