Derm STUDY - IE 2

Lecture 1: AH & Decongestants (Kaur)

Lecture 2: Fibromyalgia & Lupus (Yamaki)

Fibromyalgia Treatment

• Duloxetine (Cymbalta)

  • Avoid CrCl < 30 mL/min

  • CI: NSAIDs

  • CI: Dialysis

• Milnacipran (Savella)

  • Renal Adjustment for CrCl < 30 mL/min

  • CI: NSAIDs

• Pregabalin (Lyrica)

  • Renal Adjustment for CrCl < 60 mL/min

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• Cyclobenzaprine (Flexeril)

• Gabapentin (Neurontin)

Fibromyalgia: Medications to Avoid

• APAP, NSAIDs

• BZD, Z-Drugs

• Opioids

SLE Pathophysiology

• Apoptotic cells —> DEFECTIVE CLEARANCE —> Nuclear antigen exposure (DNA and RNA)

SLE Labs

• Antinuclear antibody (ANA)

  • Anti-dsDNA

SLE Treatments

• Hydroxychloroquine (HCQ) - gold standard

  • Anti-malarial

  • SAFE IN PREGNANCY :)

  • SE:

    • Retinal toxicity

    • EYE EXAM @ BASELINE

  • Dose:

    • Mild: 200-400 mg

      • + Low-dose glucorticoids —> short term (<3 mo)

    • Moderate: 200-400 mg

      • + Low-dose glucorticoids

      • + Steroid-sparing agent (when flare is approved)

    • Mod-to-Severe:

      • + Steroid-sparing

      • + Biologic (belimumab or anifrolumab)

• Belimumab (Benlysta)

  • MOA: B-lymphocyte stimulator

    • Autoimmune antibody-driven

    • Lupus nephritis

• Anifrolumab (Saphnelo)

  • MOA: block INF signaling

    • Inflammation INF-driven

• Glucocorticoids: high dose, IV

• Steroid-Sparing Agents

Steroid-Sparing Immunosuppressants

• Mycophenolate mofetil

• Azathiprine

• Cycophosphamide

• Rituximab

• Cyclosporine

Severe SLE Treatment

• High-dose steroids

• + Steroid-sparing agent

• + Biologic

Lecture 3: Gout & Hyperuricemia (Bach)

Primary vs. Secondary Hyperuricemia

• Primary —> uric acid overproduction

  • IDOPATHIC

  • Accelerated purine nucleotide synthesis

• Secondary

  • Diet

  • Tissue catabolism

  • Accelerated ATP degradation

Under-excretion of Uric Acid

• Primary/Idiopathic

  • Impaired excretion

• Secondary

  • Diminished renal function

  • Tubular urate secretion INHIBITOR

  • Tubular urate reabsorption ENHANCED

Thiazides & Gout

• Diuretics cause increase in serum UA (aka decreased renal clearance of UA) —> use ACEI or ARB

Gout Clinical Presentation

• 1st metatarsophalangeal joint (podagra)

• High UA levels

• Urate (MSU) crystals —> aspiration of synovial fluid

• Imaging

  • X-rays

  • MRIs

• Diagnostic

  • Male, joint redness, first MTP joint, HTN, high UA levels (5/88+ mg/dL)

• CHECK SYMPTOMS, NOT LABS —> FOR ACUTE GOUT

Gout Complications

• Uric Acid Nephrolithiasis

• Gouty Nephropathy

• Tophaceous Gout

Treatment of Acute Gout

• Acute Gout

  • 1. NSAIDs

    • Start within 24 hrs —> for 5-7 days (until resolution)

    • CI: antiplatelet, anticoag therapy; renal impairment

      • Indomethacin - 1st CHOICE

      • Naproxen

      • Sulindac

      • Celecoxib - GOOD FOR HIGH GI RISK

  • 2. Colchicine (Colcrys)

    • Renal Impairment

    • Hepatic Impairment

    • DDI: Statins, Fibric acid (myopathy)

  • 3. Corticosteroids

  • 4. ACTH

    • GOOD for CHF, renal failure, GI bleed Hx

    • CI: systemic steroid use

• Urate Lowering Therapy

ULT Indication

• Frequent gouty attacks (2+/year)

• Topus

• Damage of joints

• Renal insufficiency

• Neprholithiasis/urolithiasis

• Serum urate > 9 mg/dL

• CVD

Target Urate Level

< 6 mg/dL

Treatment of Hyperuricemia in Gout

• Xanthine Oxidase Inhibitors: decrease synthesis of UA

  • Allopurinol (Zyloprim) - 1ST LINE

  • Febuxostat (Uloric)

• Uricosurics: decrease renal reabsroption/increase renal excretion of UA

  • Probenecid

  • Lesinurad (Zurampic)

• Pegloticase (Krystexxa)

Lecture 4: Osteoarthritis (Lewis)

Risks & Symptoms

• 50+ yo

• Obesity (weight is the most modifiable risk factor)

• Women

• Weight-bearing joints

• Morning stiffness —> rest to relieve

• Crepitus - Heberden’s (outer)

• Bony enargement/tenderness - Bouchard’s (middle joints)

• LESS INFLAMMATION (degenerative, NOT AUTOIMMUE)

• Normal ESR, RF negative

• IRREVERSIBLE - damage to joint

Non-Pharm

• Strong

  • Excercise

  • Self-efficacy programs

• Conditional

  • CBT

  • Kinesiotaping (hand, knee)

  • Patellofemoral brace (knee)

• DO NOT USE

  • TENS

Treatment

• Hand

  • Oral NSAIDs

• Hip

  • Oral NSAIDS

  • Intra-articular steroids

• Knee

  • Oral NSAIDs

  • Topical NSAIDs

  • Intra-articular steroids

GI vs. CV Risk

• Nonselective- higher GI risk

• Selective- higher CV risk, lower GI risk

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• High GI Risk Pt: use Celecoxib

• High CV Risk Pt: use Naproxen

Naproxen Dose

• OTC max dose: 660 mg (naproxen sodium)

• 220 mg naproxen sodium contains 200 mg naproxen

Oral NSAID ADR & Black-Box Warning

• ADR:

  • Nausea, dyspepsia, ab pain, flatulence, diarrhea

  • GI bleeding

  • HTN

  • HF

  • Acute Renal Failure

  • Hepatitis

  • Rash, CNS effects

• CI:

  • CrCl <30 mL/min

  • CABG

• BBW:

  • Thrombotic events, MI, stroke

  • GI events in elderly —> bleeding, ulceration, perforation of stomach/intestines

Oral NSAID DDI

• Taking Aspirin (ASA) —> take oral NSAID (NOT ibuprofen or COX-2 selective) —> blocks cardioprotective effect

Topical NSAIDs

• Diclofenac

• DO NOT USE ORAL AND TOPICAL NSAIDS TOGETHER

Intraarticular Glucocortiocids

• Triamcinolone (Kenalog)

• Zilretta - Triamcinolone ER

  • ADR: sinusitis, cough, contusions

• Methylprednisolone (Depo-Medrol)

  • Minimize joint activity for several days

  • 7-10 days = peak

  • lasts 4-8 weeks

  • 24-72 hrs onset

  • Use for no more than 3 mo

Second Line Hand, Hip, Knee OA

• APAP

  • Hepatotoxicity

• Tramadol (Ultram)

  • ADR: Seizures

  • CrCl <30 min

• Duloxetine (Cymbalta)

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(KNEE OA ONLY)

• Topical Capsaicin

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• Intraarticular HA - (KNEE OA, limited benefits)

  • Synvisc-One, Monovisc, Gel-One —> 1 INJECTION ONLY

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(KNEE AND HIP)

• Opioid Analgesics

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(STRONGLY AGAINST)

• Glucosamine and Chondroitin

  • Long-term = safe

  • D/c after 3 mo

  • DDI: Warfarin

Lecture 5: Rheumatoid Arthritis (Yamaki)