Chapter 9-05: Key Medications & Interventions in Rheumatology

ANTI-INFLAMMATORY AGENTS

NSAIDS

• Mechanism: Decreased prostaglandin production and thus reduced prostaglandin-mediated capillary leakage and inflammatory cell recruitment. Most NSAIDs are non-selective inhibitors of both cyclooxygenase isoforms (COX1 and COX2).

• Clinical use: Analgesic only in most rheumatologic diseases

• Side effects: GI bleed, hypertension, hyperkalemia, AKI (ATN from inappropriate afferent arteriole constriction or tubulointerstitial nephritis)

Glucocorticoids

• Mechanism: Suppress antibody production by B cells; promote T cell apoptosis; inhibit inflammatory chemokine/cytokine production and antigen presentation by myeloid cells

• Clinical use: Rapid suppression of acute disease activity in RA, SLE, gout/pseudogout, inflammatory myopathies, PMR, etc. (1 mg/kg = common initial dose for organ-threatening rheumatologic disease)

  • - PJP prophylaxis should be provided for all patients on ≥20 mg prednisone daily for ≥3 weeks

  • - Prevention and treatment of glucocorticoid-induced osteoporosis:

    • All patients on ≥2.5 mg prednisone ≥3 months should take oral calcium and vitamin D supplementation

    • For patients >40 yr old on ≥2.5 mg prednisone ≥3 months: Check DEXA. If DEXA indicates moderate to high risk for fracture based on FRAX score, consider bisphosphonate therapy

• Side effects: Immunosuppression, osteoporosis, skin thinning, glaucoma, cataracts, weight gain, DM2, hypertension, mania/altered mental status, avascular necrosis, HPA axis suppression

Colchicine

• Mechanism: Impairs microtubule polymerization, and thus impairs neutrophil function

• Clinical use: Gout, pseudogout, familial Mediterranean fever, hypersensitivity vasculitis

• Side effects: Diarrhea, neuromuscular toxicity especially when co-administered with statins. Dose reduction needed for CKD

NON-BIOLOGIC DISEASE MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)

• Definition: DMARDs comprise a group of otherwise unrelated medications that are used to treat rheumatoid arthritis and other rheumatic conditions. The term is used in contrast to NSAIDs and steroids.

• Medications: See Table 9.16

BIOLOGIC DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (AKA “BIOLOGICS” OR BIOLOGIC DMARDs)

• Definition: DMARDs that work by targeting immune system pathways

• General principles of use:

  • - Screen for chronic infections prior to starting biologic DMARD therapy: Tuberculosis (PPD or IGRA), HepB, HepC, HIV

  • - Biologic DMARD administration: Subcutaneous medications can be self-administered; IV medications are administered at an infusion center

  • - Lab monitoring: Check CBC/CMP q2–3 months to evaluate for cytopenias and check renal/hepatic function

  • - Do not administer live vaccines while on biologics, including live influenza vaccine, Zostavax (→ use Shingrix instead), yellow fever vaccine

  • - Nomenclature: See Table 9.15 for structure-suffix relationships for therapeutic antibodies

• Medications: See Table 9.17