Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of...
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Transcript of Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of...
![Page 1: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy.](https://reader036.fdocuments.in/reader036/viewer/2022062421/56649cf05503460f949bf6d0/html5/thumbnails/1.jpg)
Cathy Sochasky, BScPharm (FCSHP)Drug Information Pharmacist
Health Sciences CentreDept. of Pharmacy
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OBJECTIVESTo discuss the various medications used to
treat the arthritic symptoms of scleroderma.To review the potential adverse
effects/interactions associated with these medications.
To understand the importance of monitoring while on these medications for their effectiveness and potential risks.
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Introduction to SclerodermaChronic multisystem autoimmune diseaseAlso termed “systemic sclerosis”Sclera – “hard” Derma – “skin”Cause unknownSymptoms, extent of skin/organs affected varies
between patients.No one specific medication to fully control
underlying disease process.Many medications used to manage specific
conditions/symptoms of this disease.
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DiagnosisComplex, often based on clinical symptomsPhysical exam (hands, knees, joints)Investigations (lab results, X-rays)2 Types: localized (skin), systemic (lung,
kidney, blood vessels & heart)
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Initial SymptomsMusculoskeletal almost always present in
ScD; degree and type variesArthritic-like which include non-specific
muscle pain (flu-like), joint stiffness/puffiness, impaired hand function
May resemble rheumatoid-like polyarthritis or carpal tunnel syndrome in early stages
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Management of Musculoskeletal Symptoms – What are the Goals and Therapeutic Options?
Goals:1.Control of pain and joint inflammation 2.Immunosuppression – maintenance3.Prevention of organ damage (organ specific tx) – skeletal muscles, GI tract, kidney, lungs)
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Management of Musculoskeletal Symptoms – What are the Goals and Therapeutic Options? cont’d
Treatment:-Combination drug treatment for rapid control of the inflammation with maintenance treatment (localized).-May require organ specific treatment (systemic)
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MedicationsNon Steroidal Anti-Inflammatory Drugs
(NSAIDs)AnalgesicsCorticosteroidsDisease Modifying Anti-Rheumatic Modifying
Drugs (DMARDs) – methotrexateOthers (azathioprine, mycophenolate,
cyclophosphamide)
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Non Steroidal Anti-Inflammatory Drugs Ibuprofen (Motrin®, Advil®)Naproxen (Naprosyn®)Diclofenac (Voltaren®)Celecoxib (Celebrex®)Ketorolac (Toradol®)
Action: - Reduce inflammation & relieve pain- No difference in effectiveness between these meds demonstrated in studies- However, some patients do respond better to one
than another.- Similar action, should not combine
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Comparative Dosage Table – Common NSAIDs
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Medication Oral Effective Dosage Range
Diclofenac (Voltaren) Immediate release
50 mg three to four times daily
Diclofenac (Voltaren) Enteric coated
50 mg twice to three times daily or 75 mg twice daily
Diclofenac (Voltaren) Extended-release
75 to 100 mg once or twice daily
Ibuprofen (Motrin) 300 mg four times daily; or 400, 600 or 800 mg three to four times daily, not to exceed 3200 mg daily
Ketoprofen (Orudis) 150 to 300 mg daily, given in 3 to 4 divided doses
Naproxen (Naprosyn) 250 to 500 mg twice daily, not to exceed 1500 mg/day
Naproxen Sodium (Anaprox) 275 mg twice daily
Sulindac (Clinoril) 150 mg twice daily, not to exceed 400 mg daily
Tolmetin (Tolectin) 400 mg three times daily, not to exceed 1800 mg daily. Control is usually achieved at doses of 200 to 600 mg daily three times daily
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To take with food or milk – Does it matter?
Most mfrs say to take NSAIDs with food or milk.Rationale – protective effect to stomach(FACT: never been studied to prove it)
Food can delay onset of its effect (only important if immediate relief needed)
Taking an NSAID on an empty stomach is not a risk for GI bleeding to occur.
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Adverse Effects of NSAIDs
1. GASTROINTESTINAL - Nausea, vomiting, heartburn
- Ulcers, bleeding, perforation
What are the risk factors for GI bleeding/perforation?Long duration of useHigh doses≥ 60 years oldHistory of ulcers/bleedingConcomitant use of alcohol, corticosteroid and/or blood thinners
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RecommendationAll patients with ≥ 1 of the above risks should:Use a low NSAID doseTake NSAID intermittently Avoid if possibleIf NSAID used, add a protective agent (omeprazole, pantoprazole) or use celecoxib
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What are the symptoms of GI bleeding? Can occur without warningBlack, tarry stoolsDark specks or blood in vomitWeakness, short of breath, pale skin, stomach pain
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Adverse Effects of NSAIDs cont’d
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2. Cardiac ToxicityDue to their mechanism of action and possibly due to blood pressure elevating effectsIf high blood pressure (BP), should have BP checked prior to and after 1-4 weeks of NSAID use.Note: Pain can increase BP, therefore NSAID use may also lower BP.Risk may be less with naproxen.
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Adverse Effects of NSAIDs cont’d
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3. Kidney effectsConcern re: Scleroderma renal crisis (kidney failure due to hypertension)Monitoring kidney function, blood pressure and electrolytes important in 1st 1-3 weeks and then every 3-6 months if prolonged use.
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Adverse Effects of NSAIDs cont’d
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Other AnalgesicsAcetaminophen (with & without codeine)May be useful for mild arthritic-like painDoes not relieve redness, stiffness or swellingLarge doses may lead to liver damage
Recommend no greater than 3-4 g/day (i.e. 6-8 Tylenol extra strength)
Avoid taking multiple meds that contain acetaminophen eg. OTC cough/cold meds
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Corticosteroids (e.g. oral prednisone, topical, injections- Depo Medrol®)
Rapid effect on inflammationUsed initially for its possible beneficial effect
on inflammation for arthritis, myositis, puffy hands, skin & lung disease
Used in low doses (≤ 7.5 mg) for short periods, often in combination
Concerns: limited data, side effects (increased risk of renal crisis, serious infections)
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DMARD- Methotrexate (oral, inj)immunosuppressive used in early stages of
skin, muscle and joint involvementoften in combination with steroidsAdvantages: weekly dosing, low cost, long
standing safety profileDisadvantages: GI symptoms (nausea, flu-like,
oral ulcers, fatigue), drug interactions, frequent blood monitoring
Dosing: Oral dose titrated to maximum of 25-30 mg once a week. (Inj used if not tolerating or oral not effective) Continue 2 mos, up to 4-6 mos
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Hydroxychloroquine- an oral alternative if intolerance or contraindication to MTX e.g. liver disease
ARE SERIOUS INFECTIONS A RISK WITH MTX?
Not really an issue with the low doses of this drug
May be due to disease itself or use of steroids
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DMARD
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DRUG INTERACTIONS1. NSAIDs + MTXnot a problem with low doses (7.5-15 mg/wk) Concern with higher doses like 150 mg
2. NSAIDs + gingko (herb) Case reports-potential for increased bleeding; use with caution or avoid
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DRUG INTERACTIONS cont’d
3. NSAIDs and SSRI antidepressants(e.g. citalopram, sertraline, fluoxetine)
increase in upper GI bleeding, main concern in those already at risk of bleedingalternatives: acetaminophen, celecoxib orswitch to different class of antidepressant oradd a drug that protects stomach (e.g. PPI)report to doctor any evidence of bleeding or if going to surgery
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DRUG INTERACTIONS cont’d
4. MTX and trimethoprim (Septra) Avoid this antibiotic (may affect white blood cells)
5. NSAIDs + BP medications (captopril, valsartan) NSAID may reduce effect of BP medication greatest risk first month dosage adj , monitoring kidney function (esp with diuretics) and BP
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WEBSITES FOR PATIENT EDUCATION ON ARTHRITIS
www.rheuminfo.comwww.arthritis.ca www.rheumatology.orgwww.arthritis.orgwww.jointhealth.org
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QUESTIONS??
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