Transcript Aches and Pains - Idaho Society of Health

Aches and Pains:
A Review of Rheumatic
Conditions and
Treatment
NAM NGUYEN, PHARM.D.
PILAR DAVILA, PHARM.D.
ISU DEPARTMENTS OF FAMILY MEDICINE AND
PHARMACY PRACTICE
MARCH 6, 2016
Disclosure
The presenters have no disclosures or conflicts of
interest
Learning Objectives
Identify common rheumatic conditions, the clinical
presentation, and the goals of treatment
Recognize common prescription and non-prescription
medications used for treatment of rheumatic
conditions
Identify common over-the-counter medications that
may require additional pharmacist attention
Rheumatic Conditions
Conditions causing inflammation, changes in joints, and
pain in the surrounding structures
Affects about 50 million people in the US
Target: Musculoskeletal system  PAIN
◦ Bones
◦ Joints
◦ Muscles
◦ Tendons
Internal organ involvement
Coexisting rheumatic conditions
ACR. Managing Your Rheumatic Disease. 2015. Available at: www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Living-Wellwith-Rheumatic-Disease/Managing-Your-Rheumatic-Disease
Rheumatic Conditions
Osteoarthritis
Vasculitis
Rheumatoid Arthritis
Ankylosing Spondylitis
Gout
Sjogren’s Syndrome
Lupus
Polymyalgia rheumatica
Carpal Tunnel
Psoriatic arthritis
Fibromyalgia
> 100 rheumatic conditions exist
General Symptoms
Joint pain or discomfort
Motion pain
Soreness to the touch
Stiffness
Stimuli
Symptomatic Response
Mild exercise
Improves
Warming of affected area
Improves
Vigorous exercise
Worsens
Falling barometric pressure
Worsens
Rising humidity
Worsens
NIH. Arthritis and Rheumatic Diseases. 2014. Available at: www.niams.nih.gov/health_info/arthritis/arthritis_rheumatic.asp#5
Statistics
Most common cause of disability in US adults
Theis KA, Murphy L, Hootman JM, Wilkie R. Arthritis Care Res. 2013; 65:1059-1069
Rheumatic
Conditions
O ST EOA RTHR ITIS
R H E U M ATO I D A RT H R ITIS
G OUT
SYSTEM IC LU P U S E RY T H EMATO SU S
Osteoarthritis
Most common form of arthritis
Degenerative joint disease
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Cartilage
Joints
Tendons and ligaments
Inflammation
Joint involvement
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Hips
Knees
Spine
Hands
Great toes
ACR. Osteoarthritis. 2015. Available at: www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Osteoarthritis
Image from: www.regenexx.com/wp-content/uploads/2008/07/knee_osteoarthritis.jpg
Osteoarthritis
Clinical Presentation
◦ Joint pain and stiffness
◦ Knobby swelling at the joint
◦ Cracking or grinding noise with joint movement
◦ Decreased function of the joint
Goals of treatment
◦ Reduce pain and stiffness
◦ Improve function
◦ Minimize adverse effects of treatment
ACR. Osteoarthritis. 2015. Available at: www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Osteoarthritis
Jo’s Experience
“Osteoarthritis affects almost every part of my life. My
favorite pastime is making wooden toys. Unfortunately, I now
also experience pain in my finger joints. My aim now is to
keep my hands moving and try to lessen the damage, so I can
continue to enjoy my hobbies for as long as possible… My
knees are beginning to give way, my left calf muscle has
become wasted and my feet are 'turning over'. I enjoy
walking, as I'm a country girl at heart, but it's increasingly
becoming agony even to pop to the supermarket in the next
street.”
NHS. Arthritis – Jo’s story. 2015. Available at: www.nhs.uk/Conditions/Arthritis/Pages/Josstory.aspx
Rheumatoid Arthritis
Most common type of autoimmune arthritis
Chronic inflammatory disorder
◦ Symmetrical joint inflammation
◦ Joint destruction
◦ Weakness and disability
Most commonly affected joints
◦ Hands
◦ Feet
Other tissue/organ involvement
ACR. Rheumatoid Arthritis. 2013. Available at: www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Rheumatoid-Arthritis
Rheumatoid Arthritis
Images from: www.hss.edu/conditions_an-in-depth-topic-review-of-rheumatoid-arthritis.asp
Rheumatoid Arthritis
Clinical Presentation
◦ Joint pain and stiffness
◦ Fatigue
◦ Low-grade fever
◦ Loss of appetite
◦ Muscle pain
◦ Joint deformity (late)
Goals of treatment
◦ Achieve remission or low
disease activity
◦ Alleviate pain
◦ Maintain function
◦ Slow progression of joint
damage
◦ Minimize adverse effects
from therapy
NIH. Rheumatoid Arthritis. 2014. Available at: www.niams.nih.gov/Health_Info/Rheumatic_Disease/default.asp
Gout
Excess uric acid  urate crystal  joint deposit
Acute gouty attack triggers:
◦ Shellfish and red meats
◦ Alcohol
◦ High fructose drinks/foods
◦ Medications
◦ Low-dose aspirin
◦ Diuretics
◦ Immunosuppressants
Can lead to kidney stones
ACR. Gout. 2015. Available at: www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Gout
Image from: www.nhs.uk/Conditions/Gout/Pages/Introduction.aspx
Gout
Acute gouty arthritis symptoms
◦ Rapid, localized onset of pain, swelling and inflammation
◦ Great toe > insteps > ankles > heels > knees > wrists >
fingers > elbows
Goals of treatment
◦ Terminate attack
◦ Prevent recurrence
◦ Prevent complications
◦ Prevent or minimize side effects of therapy
NIH. Gout. 2015. Available at: www.nlm.nih.gov/medlineplus/gout.html
Sam’s Experience
“After several nights of eating out with friends, I woke
up with my foot on fire. My toe and the whole side of
my foot were as red as a beet. I couldn't even get out of
bed…When I get gout, it keeps me off my feet for about
a week…”
Everyday Health. Living With Gout – A Patient’s Story. 2010. Available at: www.everydayhealth.com/gout/living-with-gout-a-patients-story.aspx
Systemic Lupus Erythematosus
Rare Disease
“Great Imitator”
Multisystem-autoimmune disorder
Chronic disease that causes inflammation
◦ Skin
◦ Joints
◦ Kidneys
◦ Tissue lining of the lungs (pleura) and heart (pericardium)
◦ Brain
Lupus flares
ACR. Lupus. 2015. Available at: www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Lupus
Clinical Presentation
Clinical presentation
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Fatigue, fever, weight loss
Muscle and joint pain
Butterfly rash
Inflammation of lining of lungs
and heart
◦ Neuropsychiatric and cognitive
dysfunction
◦ Indigestion, nausea, difficulty
swallowing
◦ Kidney disease
Goals of treatments
◦ Manage symptoms
◦ Minimize complications
◦ Remission
MedlinePlus. Systemic Lupus Erythematous. 2015. Available at: www.hss.edu/conditions_an-in-depth-topic-review-of-rheumatoid-arthritis.asp
Image www.coloradoarthritis.com/systemic-lupus-erythematosus-autoimmune-disorders-colorado-arthritis-center-pc-rheumatology.html
Amy’s Experience
“Heart and kidney disease are two of the more serious
complications of lupus, and it is a bit frightening to have
both at a relatively young age (37 years old). Because of
the heart disease, I am a bit more uncertain about the
future… I have been lucky in that my kidney function
has returned to almost normal after each bout with
nephritis.
SLE Lupus Foundation. Amy Thornton. 2015. Available at: www.lupusny.org/about-lupus/lupus-stories/amy-thornton
Treatment
Osteoarthritis
1st line
◦ Acetaminophen
2nd line
◦ NSAIDs
◦ Oral or topical
3rd line
◦ Opioids
Miscellaneous
◦ Non-NSAID topicals
◦ Glucosamine/Chondroitin
Acetaminophen (APAP)
Several OTC products available i.e., Tylenol®
◦ Up to 3 gm/day, scheduled
◦ Some conditions may have a lower APAP limit
◦ Liver toxicity increased in large consumption of EtOH
Managing Osteoarthritis: Helping the Elderly Maintain Function and Mobility. December 2014. AHRQ, Rockville, MD.
Phuong-Chi et al. Pain management in patients with chronic kidney disease. 2009; 2(2): 111-118
Oral NSAIDs
What does NSAID stand for?
◦ Non-Steroidal Anti- Inflammatory Drug
Prescription and OTC
Prescription Only
Ibuprofen (Motrin ®, Advil®)
Meloxicam (Mobic®)
Naproxen (Naprosyn®, Aleve®)
Diclofenac (Voltaren®)
Aspirin
Nabumetone
Topical NSAIDs
PRESCRIPTION
OTC
Diclofenac
Menthol/methyl salicylate
◦ Voltaren® Gel
◦ Avoid use of sunscreen, lotion or
other topicals
◦ Flector® Patch
◦ Most insurances do not cover
◦ Pennsaid®
◦ Generic available
Do not take with oral NSAIDs
◦ Salonpas®
◦ Patch
◦ Tigerbalm®
◦ Cream and ointment
◦ Bengay®
◦ Cream and ointment
NSAID-related
NSAIDs
Increased GI bleed and peptic ulcer disease risk,
especially in the elderly
Increased CNS sensitivity, cardiovascular risk, and
hemodynamic effects
COX-2 inhibitors similar side effects to NSAIDs
◦ Celecoxib (Celebrex®)
Patients on blood thinners or blood pressure medications
need to use with caution
Taking with steroids increases risk of GI bleed
Managing Osteoarthritis: Helping the Elderly Maintain Function and Mobility. December 2014. AHRQ, Rockville, MD.
Phuong-Chi et al. Pain management in patients with chronic kidney disease. 2009; 2(2): 111-118
Opioids
Tramadol (Ultram ®)
Hydrocodone/APAP (Vicodin®, Norco®, Lortab®)
◦ Caution with other APAP-containing products
Oxycodone (Roxicodone®)
Fentanyl (Duragesic®)
◦ Patches CANNOT be cut
Can cause constipation
Should be on a bowel regimen
Non-NSAID Topicals
Lidocaine (Lidoderm®)
◦ Able to cut patches to size
◦ Generic available
Capsaicin (Capzasin®)
◦ Counter-irritant
◦ OTC
◦ Takes a few weeks to work
Glucosamine/Chondroitin
Osteo Bi-Flex®
◦ Several manufacturers
◦ Effective for moderate to severe knee OA
◦ Most effective when used together
◦ Takes average 3 months to see effect
Rheumatoid Arthritis
Disease progression prevention
◦ Disease-modifying antirheumatolgic drugs (DMARDs)
◦ Methotrexate is 1st line
◦ Oral and injectable
◦ A person can be on one or more of these medications at the
same time
Pain relief
◦ NSAIDs are 1st line
Oral DMARDs
Methotrexate (Trexall®,MTX)
◦ Once weekly dosing
◦ Only available in 2.5mg tablets
◦ Many Black Box Warnings, make sure to dispense the
med guide
◦ Usually accompanied with folic acid prescription
Sulfasalazine (Sulfazine®)
◦ Contraindicated in patients with sulfa or salicylate allergy
Oral DMARDs
Hydroxychloroquine (Plaquenil®)
◦ Once daily
◦ Recently there have been shortages
Minocycline (Solodyn®)
◦ Twice daily
◦ A tetracycline antibiotic, not recommended in pregnancy
Leflunomide (Arava®)
◦ Loading dose x 3 days, once daily maintenance dose
◦ Inexpensive but often on back order
Injectable DMARDs
All Injectable DMARDs :
◦ Brand name only at this time
◦ Very expensive ($2000+/month)
◦ May require prior authorization
◦ Black Box Warnings for infection and malignancy
Injection medications tend to be biologics
Most are subcutaneously administered
Injectable DMARDs
What is a Black Box Warning?
◦ Warning created by the FDA to call attention to serious or
life-threatening risks
What can technicians do?
◦ Make sure to dispense the med guide
◦ Recommend the flu shot (non-live vaccine) and ensure they
are up-to-date on their vaccines
Injectable DMARDs
MOST COMMONLY PRESCRIBED
LESS COMMONLY PRESCRIBED
Adalimumab (Humira®)
Certolizumab Pegol (Cimzia®)
◦ Dosed every other week
Etanercept
(Enbrel®)
◦ Weekly or twice weekly dosing
◦ Most insurance plans will cover and
most pharmacies carry
◦ Dosed every other week
Golimumab (Simponi®)
◦ Monthly dosing
Abatacept (Orencia®)
◦ Weekly dosing
Injectable DMARDs
Least likely prescribed
◦ Infliximab (Remicade®)
◦ IV infusion with weight-based weekly dosing
◦ Premedication recommended
◦ Tocilizumab (Actemra®)
◦ SQ weekly or every other week
◦ Rituximab (Rituxan®)
◦ IV infusion
◦ Anakinra (Kineret®)
◦ SQ daily dosing
Gout: Acute Management
“Gout attack” or “flare”
Medications are only taken prn for the duration of flare
Medications only provide pain / symptom relief, no
disease modifying benefit
◦ NSAIDs
◦ Indomethacin, etodolac, celecoxib, naproxen, ibuprofen
◦ Colchicine (Colcrys®)
◦ Prednisone
Khanna et al. ACR Guidelines for Gout Part 1. 64 (10): 2012; 1431–46
Gout: Acute Management
Colchicine (Colcrys®)
◦ Taken multiple times a day as tolerated
Steroids
◦ Prednisone, prednisolone
◦ Risk of GI bleed
◦ Taken with food
◦ Can increase blood sugar and blood pressure
Khanna et al. ACR Guidelines for Gout Part 1. 64 (10): 2012; 1431–46
Gout: Chronic Maintenance
Medications must be taken daily to provide
prophylactic effect
Should not be started during an acute attack
Can induce an acute flare
Khanna et al. ACR Guidelines for Gout Part 1. 64 (10): 2012; 1431–46
Gout: Chronic Maintenance
Allopurinol (Zyloprim®)
◦ If 7-10 days missed, re-titration needed
◦ May initially cause gout flare
Febuxostat (Uloric®)
◦ Brand only
Probenecid
◦ Twice daily
◦ May initially cause gout flare
◦ Can interact with NSAIDs
Colchicine (Colcrys®)
Khanna et al. ACR Guidelines for Gout Part 1. 64 (10): 2012; 1431–46
Lupus
Pain relievers
◦ NSAIDs
◦ Ibuprofen, naproxen, diclofenac
◦ Steroids
◦ Aids with the joint pain and inflammation
Immunosuppressants
◦ Disease modifying agents
Other medications
◦ DHEA
Hahn et al. ACR Guidelines for Lupus Nephritis. 64 (6): 2012; 797– 808
Lupus medication. The Johns Hopkins. www.hopkinslupus.org/lupus-treatment/lupus-medications/ (accessed 2016 Jan 15)
Immunosuppressants
Most commonly prescribed
◦ Mycophenolate mofetil (Cellcept®, Myfortic®)
◦ Can increase risk of bleeding
◦ Cyclosporine (Neoral®, Sandimmune®, Gengraf®)
◦ 3 types available, not all are interchangeable
◦ Methotrexate
◦ Azathioprine (Imuran®)
Hahn et al. ACR Guidelines for Lupus Nephritis. 64 (6): 2012; 797– 808
Lupus medication. The Johns Hopkins. www.hopkinslupus.org/lupus-treatment/lupus-medications/ (accessed 2016 Jan 15)
Immunosuppressants
Less commonly prescribed
◦ Steroids
◦ Usually prescribed for short-term therapy or given as injection
◦ Cyclophosphamide (Cytoxin®)
◦ Hydroxychloroquine
Hahn et al. ACR Guidelines for Lupus Nephritis. 64 (6): 2012; 797– 808
Lupus medication. The Johns Hopkins. www.hopkinslupus.org/lupus-treatment/lupus-medications/ (accessed 2016 Jan 15)
Immunosuppressants
Increased risk of infection
Several medications can increase risk of cancer
Many have Black Box Warnings, dispensing the med
guide is important
Ensure vaccinations are up-to-date
Hahn et al. ACR Guidelines for Lupus Nephritis. 64 (6): 2012; 797– 808
Lupus medication. The Johns Hopkins. www.hopkinslupus.org/lupus-treatment/lupus-medications/ (accessed 2016 Jan 15)
Other medications
DHEA
◦ Available as an OTC supplement
◦ Not FDA approved
◦ Can be helpful for hair loss, joint pain, fatigue, and cognitive
dysfunction
◦ Can cause acne, facial hair, oily skin, and excessive sweating
◦ Increases risk of cancer in post menopausal women
◦ There are several patient types that should avoid DHEA
Hahn et al. ACR Guidelines for Lupus Nephritis. 64 (6): 2012; 797– 808
Lupus medication. The Johns Hopkins. www.hopkinslupus.org/lupus-treatment/lupus-medications/ (accessed 2016 Jan 15)
Technician’s Role
WHAT YOU CAN DO TO HELP PATIENT CARE?
Be Aware
Many rheumatologic conditions use NSAIDs for treatment
of pain
NSAIDs are available as OTC and prescription
More than one type of NSAID should not be taken
NSAIDs can cause high blood pressure and interact with
several blood pressure medications
Patients on blood thinners should also speak with the
pharmacist or their doctors prior to using NSAIDS or
acetaminophen
Common OTC Interactions
Acid reducers (famotidine, omeprazole, etc.) can affect the
absorption of several medications including naproxen
NSAIDs can interact with several of the medications causing
kidney injury, increasing bleed risk, and high blood pressure
Acetaminophen can interact with some medications increasing
risk of liver injury
DHEA interacts with MTX increasing the risk of liver injury