GP RHEUM AND PAIN PHARMACOLOGY

Alendronic acid

drug class: Bisphosphonate; antiresorptive agent. uses: Prevention and treatment of osteoporosis; selected other bone disorders. side effects: Upper gastrointestinal irritation, oesophagitis, musculoskeletal pain and rarely osteonecrosis of the jaw or atypical femoral fracture. important cautions: Take with plain water on an empty stomach and remain upright for at least 30 minutes; follow the specific product instructions. Avoid in oesophageal disorders that delay emptying, inability to remain upright and relevant severe renal impairment. Correct hypocalcaemia first.

Risedronate

drug class: Bisphosphonate; antiresorptive agent. uses: Prevention and treatment of osteoporosis. side effects: Gastrointestinal irritation, oesophagitis, musculoskeletal pain and rarely osteonecrosis of the jaw or atypical femoral fracture. important cautions: Follow product-specific fasting, water and upright-position instructions. Correct hypocalcaemia and vitamin D deficiency. Review renal function and report new thigh or groin pain.

Alfacalcidol

drug class: Active vitamin D analogue. uses: Disorders of calcium and bone metabolism, including selected patients with renal disease or hypoparathyroidism. side effects: Hypercalcaemia, hyperphosphataemia, nausea and weakness. important cautions: Monitor calcium, phosphate and renal function as indicated. Hypercalcaemia can cause confusion, thirst, polyuria and kidney complications. Avoid unsupervised additional vitamin D or calcium supplementation.

Colecalciferol

drug class: Vitamin D3 supplement. uses: Prevention and treatment of vitamin D deficiency; support of bone health and osteoporosis treatment when indicated. side effects: Usually well tolerated at appropriate doses; excessive intake can cause hypercalcaemia, nausea and kidney problems. important cautions: Avoid excessive cumulative dosing from multiple supplements. Use caution in hypercalcaemia, certain granulomatous disorders and relevant renal conditions. Monitor when high-dose treatment or clinical risk warrants it.

Calcium carbonate

drug class: Calcium supplement; antacid. uses: Calcium supplementation when intake is inadequate; sometimes used with vitamin D for bone health. side effects: Constipation, bloating and, with excess intake, hypercalcaemia or kidney stones. important cautions: Separate from medicines whose absorption it reduces, such as levothyroxine, iron and certain antibiotics, according to product instructions. Use caution in renal impairment and with other calcium or vitamin D products.

Methotrexate

drug class: Conventional DMARD; antimetabolite immunosuppressant. uses: Rheumatoid arthritis, psoriatic arthritis and other inflammatory diseases under specialist care. side effects: Nausea, mouth ulcers, liver toxicity, bone-marrow suppression and pneumonitis. important cautions: For inflammatory disease, usually taken ONCE WEEKLY, not daily. Monitor full blood count, liver and renal function. Folic acid is usually prescribed. Avoid in pregnancy where contraindicated; review infection risk, alcohol intake and interactions.

Hydroxychloroquine

drug class: Conventional DMARD; antimalarial immunomodulator. uses: Rheumatoid arthritis and systemic lupus erythematosus. side effects: Nausea, abdominal discomfort, rash and retinal toxicity. important cautions: Retinopathy can cause permanent visual loss; follow UK ophthalmic screening guidance based on dose, duration and risk factors. Report visual changes promptly. Dose should reflect body weight and renal function where relevant.

Leflunomide

drug class: Conventional DMARD; pyrimidine synthesis inhibitor. uses: Rheumatoid arthritis and psoriatic arthritis. side effects: Diarrhoea, nausea, raised blood pressure, hair thinning, liver toxicity and bone-marrow suppression. important cautions: Teratogenic; avoid in pregnancy and follow specialist advice for pregnancy planning and drug elimination. Monitor blood pressure, full blood count and liver function. Serious infections and liver injury require assessment.

Sulfasalazine

drug class: Conventional DMARD; aminosalicylate. uses: Rheumatoid and other inflammatory arthritis; ulcerative colitis. side effects: Nausea, headache, rash, folate deficiency and blood disorders. important cautions: Monitor full blood count, liver and renal function. Consider folate supplementation and hypersensitivity history. Seek review for fever, sore throat, bruising or severe rash.

Ibuprofen

drug class: Non-steroidal anti-inflammatory drug (NSAID). uses: Short-term relief of pain, inflammation and fever; musculoskeletal pain and inflammatory arthritis symptoms. side effects: Dyspepsia, nausea, gastrointestinal ulceration or bleeding, fluid retention and kidney injury. important cautions: Use the lowest effective dose for the shortest time. Avoid or seek advice with peptic ulcer disease, kidney disease, heart failure, anticoagulants or pregnancy. Do not combine with other NSAIDs.

Diclofenac

drug class: NSAID. uses: Inflammatory and musculoskeletal pain, arthritis and selected acute pain conditions. side effects: Dyspepsia, gastrointestinal bleeding, fluid retention and kidney injury. important cautions: Increased cardiovascular risk, particularly with systemic formulations. Avoid in established ischaemic heart disease, cerebrovascular disease, peripheral arterial disease or significant heart failure under relevant UK restrictions. Avoid combining with other NSAIDs.

Naproxen

drug class: NSAID. uses: Inflammatory arthritis, musculoskeletal pain, acute gout and period pain. side effects: Dyspepsia, peptic ulceration or bleeding, fluid retention and kidney injury. important cautions: Gastrointestinal and renal risks remain significant. Consider gastroprotection when indicated. Avoid combining with other NSAIDs; review anticoagulants, cardiovascular disease, kidney function and pregnancy.

Etoricoxib

drug class: Selective cyclo-oxygenase-2 (COX-2) inhibitor; NSAID. uses: Symptomatic treatment of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis and acute gout in eligible patients. side effects: Dyspepsia, oedema, hypertension and kidney injury. important cautions: Can increase cardiovascular risk and blood pressure. Contraindications include certain cardiovascular conditions and uncontrolled hypertension. Use the lowest effective dose for the shortest time; consider renal function and gastrointestinal risk.

Morphine

drug class: Strong opioid analgesic. uses: Severe pain, including acute pain and palliative-care pain. side effects: Constipation, nausea, vomiting, sedation, itching and respiratory depression. important cautions: Risk of dependence, overdose and fatal respiratory depression, especially with alcohol, benzodiazepines or other sedatives. Reduce or review dosing in renal impairment. Provide a bowel regimen when appropriate and monitor sedation and breathing.

Oxycodone

drug class: Strong opioid analgesic. uses: Severe pain when an opioid is appropriate. side effects: Constipation, nausea, vomiting, drowsiness and respiratory depression. important cautions: Dependence and overdose risk; interactions with alcohol, benzodiazepines and other sedatives can be fatal. Use the lowest effective dose for the shortest appropriate duration and review renal or hepatic impairment.

Codeine

drug class: Opioid analgesic; partly converted to morphine. uses: Mild-to-moderate pain when other options are unsuitable; some formulations are used for cough or diarrhoea under specific indications. side effects: Constipation, nausea, drowsiness and respiratory depression. important cautions: Dependence and overdose risk. Avoid alcohol and other sedatives. Effect and toxicity vary with CYP2D6 metabolism. Follow age-specific restrictions and avoid breastfeeding where contraindicated.

Tramadol

drug class: Opioid analgesic with serotonin and noradrenaline reuptake inhibition. uses: Moderate-to-severe pain when an opioid is appropriate. side effects: Nausea, dizziness, constipation, drowsiness and sweating. important cautions: Can cause seizures and serotonin syndrome, especially with serotonergic medicines. Dependence and respiratory depression are possible. Avoid alcohol and sedative combinations; consider renal function and interactions.

Dihydrocodeine

drug class: Opioid analgesic. uses: Moderate-to-severe pain when an opioid is appropriate. side effects: Constipation, nausea, dizziness, drowsiness and respiratory depression. important cautions: Dependence and overdose risk. Avoid alcohol and other sedatives; monitor breathing and sedation. Review dose in renal impairment and use the lowest effective dose for the shortest appropriate duration.

Paracetamol

drug class: Non-opioid analgesic and antipyretic. uses: Mild-to-moderate pain and fever. side effects: Usually well tolerated at recommended doses; overdose can cause severe liver injury. important cautions: Check all combination products to avoid accidental duplicate dosing. Use lower limits or seek advice in low body weight, malnutrition, significant liver disease or heavy alcohol use. Suspected overdose requires urgent medical assessment even if the person feels well.

Allopurinol

drug class: Xanthine oxidase inhibitor; urate-lowering therapy. uses: Long-term prevention of gout flares by reducing uric acid; selected other hyperuricaemic conditions. side effects: Rash, gastrointestinal upset and liver abnormalities; rare severe hypersensitivity, including Stevens–Johnson syndrome. important cautions: Start at a low dose and titrate according to urate and renal function. Stop and seek urgent medical advice for a new rash or systemic illness. Major interaction with azathioprine and mercaptopurine requires specialist management.