CLINICAL PHARMACY IN RHEUMATOLOGY. RHEUMATIC DISEASES. Rheumatic diseases (rheumatism) are painful conditions that affect millions. These diseases cause inflammation, swelling, and pain in the joints or muscles.
CLINICAL PHARMACY IN RHEUMATOLOGY
Some forms of rheumatism are called non-articular rheumatism and may affect the soft tissues causing pain throughout the body. Conditions like tendonitis and fibromyalgia fall into this category. As well, non-articular rheumatism can be localized to specific areas in the body. Bursitis is a non-articular form of rheumatism that affects and inflames the bursa, which are special sacs that protect joints and overlapping muscles. Bursitis most frequently occurs at the site of one joint that may have been injured through overuse.
OA is not a normal part of aging; it usually affects the knees, hips, lower back, neck, and fingers.
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.
RA is sometimes called a crippling disease. That's because it can result in permanent joint damage and deformity.
RA signs and symptoms include:
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.
SLE or systemic lupus erythematosus is another autoimmune disease; the cause of SLE is unknown.
Lupus signs and symptoms include:
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.
Ankylosing 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:
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.
Sjogren'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:
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.
Venus Williams Diagnosed With Sjogren’s Syndrome
NSAIDs can be very effective against inflammation, but they do not prevent tissue damage. Even when NSAIDs are controlling the inflammation, the joint or organ damage of arthritis can continue to get worse. NSAIDs only lessen pain and discomfort. They do not affect underlying disease.
Non steroidal anti-inflammatory drugs (NSAIDs) are examples of drugs that act on enzymes. NSAIDs inhibits the enzyme cyclo-oxygenase (COX) which catalyses a reaction in the biochemical pathway that results in the production of prostaglandins, important mediators in the inflammatory response.
The more an NSAID blocks COX-1, the greater is its tendency to cause ulcers and promote bleeding. One NSAID, celecoxib (Celebrex), blocks COX-2 but 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 can be classified based on their chemical structure or mechanism of action. Older NSAIDs were known long before their mechanism of action was elucidated and were for this reason classified by chemical structure or origin. Newer substances are more often classified by mechanism of action.
Propionic acid derivatives
Acetic acid derivatives
Enolic acid (Oxicam) derivatives
Fenamic acid derivatives( Fenamates )
Selective COX-2 inhibitors (Coxibs)
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.
NSAIDs irritate the gastrointestinal (GI) tract (the digestive system--your esophagus, stomach, and intestines). They increase the production of gastric acid, and they harm the gastric lining. NSAIDs aggravate ulcers and GI bleeding. Up to 5 percent of people who use NSAIDs for a year develop ulcers, bleeding, or tears in the GI tract. The risks are higher for older patients, patients with a history of GI problems, and patients with heart disease.
NSAIDs make it harder for the platelets in your blood to clump together at the site of an injury. This can cause bleeding problems. Aspirin especially has this effect. Before you have surgery, you should stop taking aspirin for two weeks to prevent bleeding problems.
NSAIDs can be toxic to your liver. You will not feel this, but elevated levels of certain liver enzymes can easily be seen in blood tests. Liver function almost always returns to normal when you stop taking NSAIDs.
NSAIDs can make it hard for your kidneys to get rid of some kinds of wastes. If you have a history of kidney problems, or if your disease may affect your kidneys, your doctor will use NSAIDs with caution.
Some people get skin reactions and rashes from NSAIDs. Some get a combination of runny nose, polyps in the nose, and asthma. Different kinds of NSAIDs can have different side effects. Salicylates can cause problems with hearing. Other kinds of NSAIDs can cause headaches and confusion, especially in elderly patients. Many of the possible side effects depend on your health and the disease for which you are being treated.
Individuals can react very differently to the same NSAIDs. You and your doctor must work together to find the type and dose of NSAID that controls your symptoms without causing unwanted side effects.
CORTICOSTEROIDSCorticosteroids may regulate gene expression in several ways. Corticosteroids enter the cell to bind to GR in the cytoplasm that translocate to the nucleus. GR homodimers bind to GRE in the promoter region of steroid-sensitive genes, which may encode anti-inflammatory proteins. Less commonly, GR homodimers interact with negative GREs to suppress genes, particularly those linked to side effects of corticosteroids. Nuclear GR also interact with coactivator molecules, such as CBP, which is activated by proinflammatory transcription factors, such as NF-B, thus switching off the inflammatory genes that are activated by these transcription factors. Other abbreviations: SLPI: secretory leukoprotease inhibitor; MKP-1: mitogen-activated kinase phosphatase-1; IB-: inhibitor of NF-B; GILZ: glucocorticoid-induced leucine zipper protein; POMC: proopiomelanocortin; CRF: corticotrophin-releasing factor.
Corticosteroids can have many unwanted effects on your body. Whether or not you develop these complications depends on many factors: what type of corticosteroid you take, your dose, the length of time you are on it, and how sensitive your body is to these hormones. The most common side effects are.
Corticosteroids are contraindicated in systemic fungal infectionsand in people who are hypersensitive to drug formulations. They should be used with caution in clients at risk forinfections (they may decrease resistance), clients with infections(they may mask signs and symptoms so that infectionsbecome more severe before they are recognized and treated),diabetes mellitus (they cause or increase hyperglycemia),peptic ulcer disease, inflammatory bowel disorders, hypertension,congestive heart failure, and renal insufficiency.
Chloroquine and hydroxychloroquine
The term biological agents encompasses tumour necrosis factor (TNF)-alpha blockers (infliximab, etanercept, and adalimumab) and other agents, including abatacept, anakinra, and rituximab.
Current 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.
The use of disease-modifying anti-rheumatic drugs (DMARDs) is limited by potentially serious side-effects, and therefore patients who are taking these drugs should be monitored on a regular basis as in the table below. Note throughout that, whilst absolute values are useful indicators, trends are also important. Hence any rapid fall or consistent downward trend in any parameter warrants extra vigilance.