CLINICAL PHARMACY IN RHEUMATOLOGY

BASIC QUESTIONS

Clinical pharmacology of nonsteroidal anti-inflammatory drugs

Clinical pharmacology of glucocorticoids

Clinical pharmacology of disease-modifying antirheumatic drugs

RHEUMATIC DISEASES

Rheumatic diseases (rheumatism) are painful conditions that affect millions. These diseases cause inflammation, swelling, and pain in the joints or muscles.

Some rheumatic diseases like osteoarthritis are the result of "wear and tear" to the joints. Other rheumatic diseases, such as rheumatoid arthritis, happen when the immune system goes haywire; the immune system attacks the linings of joints, causing joint pain, swelling, and destruction.

Fibromyalgia

OsteoarthritisOA is not a normal part of aging; it usually affects the

knees, hips, lower back, neck, and fingers. The signs and symptoms of OA include: Pain in joint Joint swelling Joint may be warm to touch Joint stiffness Muscle weakness and joint instability Pain when walking Difficulty gripping objects Difficulty dressing or combing hair Difficulty sitting or bending over  To diagnose OA, doctor will ask the patient about medical

history and symptoms and do a physical exam. Blood tests may help rule out other types of arthritis or medical problems. A joint fluid sample from an affected joint may also be examined to eliminate other medical problems.

Osteoarthritis

Rheumatoid ArthritisRA is sometimes called a crippling disease. That's because it

can result in permanent joint damage and deformity.                                                                               

RA signs and symptoms include: Joint pain, stiffness, and swelling Involvement of multiple joints (symmetrical pattern) Other organ involvement Joint stiffness, especially in the morning Fatigue Fevers Lumps called rheumatoid

nodules                                                                  To diagnose RA, doctor will ask about medical history and do

a physical examination. Also, X-rays and blood tests will likely be taken. One blood test may be for rheumatoid factor; it is positive in 70% to 80% of those with RA.

Rheumatoid Arthritis

LupusSLE or systemic lupus erythematosus is another autoimmune disease;

the cause of SLE is unknown. Lupus signs and symptoms include: Joint pain Fatigue Joint stiffness Rashes, including the"butterfly rash" across the cheeks   Sun sensitivity Hair loss Discoloration of the fingers or toes when exposed to cold (called

Raynaud's phenomenon) Internal organ involvement, such as the kidneys Blood disorders, such as anemia and blood clots Chest pain from inflammation of the lining of the heart or lungs Seizures or strokes                                                                              To diagnose lupus, doctor will ask about medical history, do a physical

exam, and order lab tests of blood and urine samples. One blood test is the antinuclear antibody test (ANA).  Most people with lupus have a positive ANA blood test.

Systemic lupus erythematosus

Ankylosing SpondylitisAnkylosing Spondylitis (AS) usually starts gradually as lower back

pain. The hallmark feature of AS is the involvement of the joints at the base of the spine. This is where the spine attaches to the pelvis, also known as the sacroiliac joints.

Ankylosing spondylitis is more common in young men, especially from the teenage years to age 30.

AS symptoms include: Gradual pain in the lower back and buttocks Lower back pain that worsens and works its way up the spine Pain felt between the shoulder blades and in the neck Pain and stiffness in the back, especially at rest and on arising Pain and stiffness get better after activity Pain in the middle back and then upper back and neck (after 5-10

years)                                                                              With progression of AS, the spine may become stiffer. It may become

difficult to bend for common everyday activities.To diagnose AS, doctor will ask about medical history and perform a

physical exam. X-rays of the back looking at the sacroiliac joints may help in making an AS diagnosis. A positive blood test for HLA-B27 protein may help confirm a diagnosis.

Ankylosing Spondylitis

Sjogren's SyndromeSjogren's syndrome is an inflammatory, autoimmune disease. It can

occur with other autoimmune diseases such as RA and lupus, but also on its own. Although the cause of Sjogren's is unknown, it is more common in women.                                                                             

Sjogren's signs and symptoms include: Dry eyes (the glands in eyes do not give adequate tears) Eye irritation and burning Dry mouth (the glands in mouth do not give adequate saliva) Dental decay, gum disease, thrush Swelling of the parotid glands on the sides of the face Joint pain and stiffness (rarely) Internal organ diseases (rarely) To diagnose Sjogren's syndrome, doctor will do a physical exam and

ask about medical history. Blood tests and other tests may also be performed. A simple biopsy of the inner lip or other area may help confirm the diagnosis.

Sjogren's Syndrome

Venus Williams Diagnosed With Sjogren’s Syndrome

Therapeutic Strategies

The treatment of patients with inflammation involves two primary goals: first, the relief of symptoms and the maintenance of function, which are usually the major continuing complaints of the patient; and second, the slowing or arrest of the tissue-damaging process.

NSAIDs can be classified based on their chemical structure or mechanism of action

Salicylates Aspirin (acetylsalicylic acid) Diflunisal Salsalate

NSAIDsPropionic acid derivatives Ibuprofen Naproxen Fenoprofen Ketoprofen Flurbiprofen Oxaprozin Acetic acid derivatives Indomethacin Sulindac Etodolac Ketorolac Diclofenac (Safety alert by FDA) Nabumetone

NSAIDsEnolic acid (Oxicam) derivatives Piroxicam Meloxicam Tenoxicam Droxicam Lornoxicam Isoxicam Fenamic acid derivatives( Fenamates ) Mefenamic acid Meclofenamic acid Flufenamic acid Tolfenamic acid

NSAIDsSelective COX-2 inhibitors (Coxibs) Celecoxib (FDA alert) Rofecoxib (withdrawn from market) - increased cardiovascular

thrombotic events Valdecoxib (withdrawn from market) - increased cardiovascular

thrombotic events Parecoxib FDA withdrawn Lumiracoxib TGA cancelled registration Etoricoxib FDA withdrawn Firocoxib used in dogs and horses Sulphonanilides Nimesulide (systemic preparations are banned by several countries for

the potential risk of hepatotoxicity) Others Licofelone acts by inhibiting LOX (lipooxygenase) & COX and hence

known as 5-LOX/COX inhibitor

InflammationThe cell damage associated with inflammation acts on cell membranes to cause leukocytes to release lysosomal enzymes; arachidonic acid is then liberated from precursor compounds, and various eicosanoids are synthesized. The cyclooxygenase (COX) pathway of arachidonate metabolism produces prostaglandins, which have a variety of effects on blood vessels, on nerve endings, and on cells involved in inflammation. The lipoxygenase pathway of arachidonate metabolism yields leukotrienes, which have a powerful chemotactic effect on eosinophils, neutrophils, and macrophages and promote bronchoconstriction and alterations in vascular permeability.

Cyclooxygenase isoforms

The discovery of two cyclooxygenase isoforms (COX-1 and COX-2) led to the concept that the constitutive COX-1 isoform tends to be homeostatic in function, while COX-2 is induced during inflammation and tends to facilitate the inflammatory response. On this basis, highly selective COX-2 inhibitors have been developed and marketed on the assumption that such selective inhibitors would be safer than nonselective COX-1 inhibitors but without loss of efficacy.

The more an NSAID blocks COX-1, the greater is its tendency to cause ulcers and promote bleeding. But celecoxib (Celebrex), blocks COX-2 and has little effect on COX-1, and is therefore further classified as a selective COX-2 inhibitor. Selective COX-2 inhibitors cause less bleeding and fewer ulcers than other NSAIDs.

NSAIDs are generally indicated for the symptomatic relief of the following conditions:

Rheumatoid arthritis Osteoarthritis Inflammatory arthropathies (e.g. ankylosing spondylitis, psoriatic

arthritis, Reiter's syndrome) Acute gout Dysmenorrhoea (menstrual pain) Metastatic bone pain Headache and migraine Postoperative pain Mild-to-moderate pain due to inflammation and tissue injury Pyrexia (fever) Ileus Renal colic They are also given to neonate infants whose ductus arteriosus is

not closed within 24 hours of birth Aspirin, the only NSAID able to irreversibly inhibit COX-1, is also

indicated for inhibition of platelet aggregation.

Complications of NSAIDsNSAIDs are safe drugs. However, they have many side effects. The side effects happen more often when they are used over long periods of time, which is common in arthritis patients. Some of the side effects can become very serious. Central nervous system: Headaches, tinnitus, and

dizziness. Cardiovascular: Fluid retention hypertension,

edema, and rarely, congestive heart failure. Gastrointestinal: Abdominal pain, dysplasia, nausea,

vomiting, and rarely, ulcers or bleeding. Hematologic: Rare thrombocytopenia, neutropenia,

or even aplastic anemia. Hepatic: Abnormal liver function tests and rare liver

failure. Pulmonary: Asthma. Rashes: All types, pruritus. Renal: Renal insufficiency, renal failure,

hyperkalemia, and proteinuria.

Choice of NSAID

All NSAIDs, including aspirin, are about equally efficacious with a few exceptions—tolmetin seems not to be effective for gout, and aspirin is less effective than other NSAIDs (eg, indomethacin) for ankylosing spondylitis.

Thus, NSAIDs tend to be differentiated on the basis of toxicity and cost-effectiveness. For example, the gastrointestinal and renal side effects of ketorolac limit its use. Some surveys suggest that indomethacin or tolmetin are the NSAIDs associated with the greatest toxicity, while salsalate, aspirin, and ibuprofen are least toxic. The selective COX-2 inhibitors were not included in these analyses.

Choice of NSAID (cont’d) For patients with renal insufficiency, nonacetylated salicylates may

be best. Diclofenac and sulindac are associated with more liver function test abnormalities than other NSAIDs. The relatively expensive, selective COX-2 inhibitor celecoxib, is probably safest for patients at high risk for gastrointestinal bleeding but may have a higher risk of cardiovascular toxicity. Celecoxib or a nonselective NSAID plus omeprazole or misoprostol may be appropriate in patients at highest risk for gastrointestinal bleeding; in this subpopulation of patients, they are cost-effective despite their high acquisition costs.

The choice of an NSAID thus requires a balance of efficacy, cost-effectiveness, safety, and numerous personal factors (eg, other drugs also being used, concurrent illness, compliance, medical insurance coverage), so that there is no best NSAID for all patients. There may, however, be one or two best NSAIDs for a specific person.

CORTICOSTEROIDS Most of the known effects of the glucocorticoids

are mediated by widely distributed glucocorticoid

receptors

CORTICOSTEROIDS

Glucocorticoids. Anti-Inflammatory and Immunosuppressive effects Glucocorticoids cause vasoconstriction when applied

directly to the skin, possibly by suppressing mast cell degranulation. They also decrease capillary permeability by reducing the amount of histamine released by basophils and mast cells.

The anti-inflammatory and immunosuppressive effects of glucocorticoids are largely due to the actions described above. In humans, complement activation is unaltered, but its effects are inhibited. Antibody production can be reduced by large doses of steroids, although it is unaffected by moderate doses (eg, 20 mg/d of prednisone).

Uses of Corticosteroids

The most commonly used corticosteroids are prednisone, prednisolone, and methylprednisolone. Corticosteroids can be given orally or put directly into the bloodstream through an intravenous needle. They can also be injected directly into an inflamed spot. Corticosteroid cream can be rubbed on the skin.

Corticosteroids are powerful drugs. But they are also highly toxic. Doctors have different opinions about how corticosteroids should be used.

Corticosteroids can't cure a disease. But they do seem to affect the development of some diseases, including rheumatoid arthritis (RA).

Some Commonly Used Natural and Synthetic Corticosteroids for General Use

Short- to medium-acting glucocorticoids:

 Hydrocortisone (cortisol)

Cortisone

Prednisone

Prednisolone

Methylprednisolone

Some Commonly Used Natural and Synthetic Corticosteroids for General Use

Intermediate-acting glucocorticoids 

Triamcinolone

Paramethasone

Fluprednisolone Long-acting glucocorticoids 

  Betamethasone

Dexamethasone

CORTICOSTEROIDS

Withdrawal

When stop taking corticosteroids, the doses will be slowly reduced over a period of days or weeks. Even if patient has only been taking steroids for a few weeks, he will still need to taper off. Corticosteroid withdrawal can be very difficult for body. In many patients, the disease symptoms become worse. Some people experience a sickness that includes fevers, nausea, vomiting, low blood pressure, and low blood sugar. Others have withdrawal symptoms that include muscle and joint pain, weight loss, fever, and headaches. If patient have problems coming off corticosteroids, doctor will have taper off the drug more slowly.

Different people, and different diseases, react very differently to corticosteroids.

Choosing the right DMARDCurrent evidence suggests that combinations of

DMARDs are more effective, and probably less toxic, than monotherapy. Methotrexate is often used as an anchor drug, combined with hydroxychloroquine, sulfasalazine or leflunomide. An anti-TNF-alpha drug such as etanercept or infliximab may also be used in combination. There is a stronger evidence base for the disease-modifying effects of methotrexate, sulfasalazine, leflunomide and intramuscular gold than for hydroxychloroquine, penicillamine, oral gold, ciclosporin or azathioprine, although these agents do improve symptoms and some objective measures of inflammation. The choice of first agent or combination of agents should be based on a risk/benefit analysis for individual patients.