Pharmacotherapy for Rheumatoid Arthritis Lesinurad (Zurampic ) helps your body get rid of uric acid

when you void

 Non-steroidal Anti-inflammatory Drugs – swelling
and pain Preobenecid - helps the kidneys excrete uric acid

 DMARDS disease-modifying antirheumatic drugs,
 Corticosteroids – fights inflammation
RA is an autoimmune inflammatory condition.
It occurs when the body’s immune system mistakenly attacks
healthy cells in the synovial tissues or linings of the joints.
Allopurinol (Aloprim, Zyloprim) – reduces uric acid
production
Febuxostat (Uloric) reduces uric acid production
Colchicine – reduces uric acid production and inflammation
Rheumatoid arthritis

This reaction causes inflammation, pain, and swelling. It  is an autoimmune and inflammatory disease causing
usually occurs in the hands, wrists, ankles, and knees on both inflammation in your joints
sides of the body.
 Most common in women
Over time, repeated bouts of swelling can lead to joint
damage.  Smoking increases risk

For unknown reasons, more women than men get RA  Obesity

Gout is also an inflammatory disorder, but it is not an
autoimmune condition. Instead, a person with gout develops
high levels of uric acid in their blood.
Uric acid is present in foods and drinks, and taking certain
medications can also increase the amount of uric acid in the
body.
These uric acid crystals can deposit in the synovial tissues,
especially in the hands, feet, and elbows.
Pharmacotherapy for Gout
 Anti-Gout
 Allopurinol (Aloprim, Zyloprim)
 Febuxostat (Uloric)
 Swelling, inflammation, pain, stiffness
- which means that your immune system attacks
healthy cells in your body by mistake, causing
inflammation (painful swelling) in the affected parts of
the body.
- RA commonly affects joints in the hands, wrists, and
knees. In a joint with RA, the lining of the joint
becomes inflamed, causing damage to joint tissue.
This tissue damage can cause long-lasting or chronic
pain, unsteadiness (lack of balance), and deformity
(misshapenness).
Breastfeeding
Women who have breastfed their infants have
a decreased risk of developing RA.

First-Generation Nonsteroidal Anti-inflammatory Drugs

 Colchicine (Mitigare)
(NSAIDs)—Nonaspirin
 Pegloticase (Krystexxa)
1. Ibuprofen (e.g., Motrin, Advil, Nuprin),
 Preobenecid
2. naproxen (Aleve),
Allopurinol (Aloprim, Zyloprim) – reduces uric acid
production 3. indomethacin (Indocin),

Febuxostat (Uloric) reduces uric acid production 4. piroxicam (Feldene)

Colchicine – reduces uric acid production and inflammation 5. sulindac (Clinoril

Pegloticase (Krystexxa) breaks down uric acid

NSAIDs are medicines that decrease pain and swelling.
Some NSAIDs are available over-the-counter, like ibuprofen
and naproxen sodium. Stronger NSAIDs like indomethacin and
celecoxib must be prescribed by a doctor.
Taking NSAIDs can lead to kidney disease over time or
make kidney disease worse. NSAIDs may not be
recommended when you have kidney disease even for the
treatment of gout attacks.
Aspirin and other analgesics are used for pain. Topical
medications containing medication such as menthol,
salicylate, and trolamine are usually creams or gels that are
rubbed into muscles and joints. Examples are Absorbine,
Bengay, Icy Hot, and capsaicin. Stronger pain relief can be
obtained by combining analgesics and antidepressants.
Uses
• Primary use is for rheumatoid arthritis and osteoarthritis
• Reduce inflammation, pain of dysmenorrhea, and headache
• Decrease fever
Action:
Suppress inflammation by inhibiting both cyclooxygenases 1
and 2 (COX-1 and COX-2), enzymes that are responsible for
the synthesis of prostaglandins. NSAIDs inhibit the formation
and release of prostaglandin.
Side Effects: Dyspepsia, anorexia, nausea, vomiting, fluid
retention Rash, dizziness, heartburn, GI bleeding
 Do not take on an empty stomach
 blurred vision, ringing of ears may indicate toxicity
 Report change in urine, increase weight , edema may
indicate nephrotoxicity
Nursing Implications
1. Take with food or milk to reduce GI distress.
2. Do not crush or chew enteric-coated tablets.
3. Teach patient to avoid alcohol and aspirin products
while taking NSAIDs.
4. Patient should avoid all NSAIDs for a least 1 week
before surgery or invasive diagnostics.
 To prevent bleeding pboblems
 Theres also risk from the fomarnation of thrombus
They’re designed to release medicine slowly into your body
over time and crushing them could cause an overdose.
Your stomach acid could stop them working without their
special coating. They could be harmful to the lining
of your stomach without their special coating. They may taste
unpleasant without their special.
Chewed, crushed, or sucked tablets may cause
oropharyngeal ulceration. Slow-release;
Note: crushing, chewing, or dissolving tablets can cause rapid
release and absorption of potentially fatal dos
Action: Inhibits prostaglandin synthesis by selectively
inhibiting cyclooxygenase 2 (COX-2), an enzyme needed for
biosynthesis, which suppresses pain and inflammation while
posing a lower risk of gastric ulceration
Contraindications and Precautions
 Risk of myocardial infarction (MI) and stroke and
other serious cardiovascular events.
 Not use during pregnancy, especially the third
trimester.
 Impair renal function.
 Can precipitate an allergic reaction in patients allergic
to sulfonamides. •
 Do not use in patients with a history of hypertension,
edema, heart failure, or kidney disease
Use of NSAIDs, including CELEBREX, during the third
trimester of pregnancy increases the risk of premature
closure of the fetal ductus arteriosus. Avoid use of NSAIDs,
including CELEBREX, in pregnant women starting at 30
weeks of gestation.
Fetal ductus arterious - Patent ductus arteriosus (PDA) is an
extra blood vessel found in babies before birth and just after
birth. In most babies who have an otherwise normal heart,
the PDA will shrink and close on its own in the first few days of
life. If it stays open longer, it may cause extra blood to flow to
the lungs.
Sulfonamindes: are antibiotics Sulfonamides, or
"sulfa drugs," are a group of medicines used to treat
bacterial infections. They may be prescribed to treat urinary
tract infections (UTIs), bronchitis, eye infections, bacterial
meningitis, pneumonia, ear infections, severe burns, traveler's
diarrhea, and other conditions.
Nursing Implications
1. Give with milk or full glass of water to enhance
absorption.
2. Do not break, crush, chew, or dissolve caps.
3. Teach patient to avoid concurrent use of alcohol to
decrease gastrointestinal (GI) irritation.
4. Monitor for GI irritation, bleeding episodes, or renal
impairment.
Disease-modifying antirheumatic drugs (DMARDs)
Traditional DMARDs target the entire immune system,
whereas biologics work by targeting specific steps in the
inflammatory process, and JAK inhibitors block action in your
body to help prevent the inflammation from even starting.
Disease-modifying anti-rheumatic drugs (DMARDs) act by
altering the underlying disease rather than treating symptoms.
They're not painkillers, but they'll reduce pain, swelling and
stiffness over a period of weeks or months by slowing down
the disease and its effects on the joints.
If anti-inflammatory drugs do not reduce the inflammation
adequately, disease-modifying antirheumatic drugs
(DMARDs) may be used in patients with rheumatoid
arthritis.
These medications suppress the autoimmune response, but in
doing so they suppress immunity systemically.
Although not able to cure the disease, these drugs may be
able to slow the continual joint destruction.
The goal of treatment is not cure but continued joint mobility.
Examples of DMARDs include Rheumatrex (methotrexate),
Neoral (cyclosporine), and Azulfidine (sulfasalazine). One
interesting example is Solganal (gold aurothioglucose).
Given by injection or sometimes orally, it prevents joint
damage and disability.
Gold tends to work best in the early stages of rheumatoid
arthritis, although it may also help with other types.
Gold is used infrequently because the other DMARDs listed
are more effective.
Actions: Reduce joint destruction and slow disease
progression of rheumatoid arthritis
Contraindications: Demyelinating disorders, severe heart
failure, active infections (tuberculosis [TB], hepatitis B virus
[HBV])
Precautions
• Patients who are immunosuppressed, diabetes, liver
dysfunction, prone to infections Uses
Methotrexate is first-line therapy
Methotrexate can lead to a deficiency of Folic acid, resulting
in possible megaloblastic anemia and injury to the oral and GI
mucosa. Folic acid is essential in the synthesis of DNA. Folic
acid supplementation (5mg/wk) is recommended to minimize
the risk of deficiency and to reduce the possibility of side
effects in clients taking low-dose methotrexate for rheumatoid
arthritis
A nurse prepares to administer folic acid to a client taking
methotrexate (Rheumatrex) for rheumatoid arthritis. The client
asks the nurse, ―Why did the physician prescribe this
medication?‖ How should the nurse respond?
A. The medication will reduce gastrointestinal problems
and mouth sores
Side Effects:
Biologic DMARDs—serious infections (bacterial sepsis,
invasive fungal infections, TB, HBV infection), cancer,
hematologic disorders, severe allergic reactions
Methotrexate—hepatic fibrosis, bone marrow suppression,
gastrointestinal (GI) ulceration, pneumonitis
Hydroxychloroquine—retinal damage (often irreversible
leading to blindness)
Nursing Considerations:
1. Teach patient about signs of infection and to report
promptly.
2. Monitor for side effects.
Hepatic fibrosis - Hepatic fibrosis is overly exuberant wound
healing in which excessive connective tissue builds up in
the liver. The extracellular matrix is overproduced, degraded
deficiently, or both. The trigger is chronic injury, especially if
there is an inflammatory component
Bone marrow suppression is when fewer blood cells are
made in the marrow. It's a common side effect of some strong
medicines, such as chemotherapy. Bone marrow
suppression can cause: An
emia. This is a decrease in red blood cells, which carry
oxygen.
Gout
A type of inflammatory arthritis, excess amount and defect in
the metabolism of uric acid. Causes uric acid crystals to form
in the joints and the patient will experience severe pain,
inflammation, redness, and limited mobility.
The patient has issues with HIGH URIC ACID levels in the
body because:
• The patient is producing too much uric acid or not
excreting it normally.
• Uric acid is a waste product created during the
normal breakdown of purines, naturally occurring
substances found in foods such as liver, mushrooms,
anchovies, mackerel and dried beans according to
the NIAMS. Uric acid is normally cleaned out of the
blood by the kidneys, and passes out of
the body along with urine
• internal organ meats (liver, kidneys, sweetbreads
(thymus and pancreas)),
• other red meats
• alcohol (especially beer)
• seafood (anchovies, sardines, scallops)
It tends to most commonly occur in the BIG TOE, but can
affect the fingers, elbow, knee, small toes, and wrist.
The patient has issues with HIGH URIC ACID levels in the
body because:
• The patient is producing too much uric acid or not
excreting it normally.
• Uric acid is a waste product created during the
normal breakdown of purines, naturally occurring
substances found in foods such as liver, mushrooms,
anchovies, mackerel and dried beans according to
the NIAMS. Uric acid is normally cleaned out of the
blood by the kidneys, and passes out of
the body along with urine
• internal organ meats (liver, kidneys, sweetbreads
(thymus and pancreas)),
• other red meats
• alcohol (especially beer)
• seafood (anchovies, sardines, scallops)
It tends to most commonly occur in the BIG TOE, but can
affect the fingers, elbow, knee, small toes, wrist.
• Pharmacotherapy for Gout
• Febuxostat (Uloric)
• Allopurinol (Zyloprim)
• Probenecid,
• Pegloticase (Krystexxa)
• Colchicine
Contraindications and Precautions
• Severe gastrointestinal (GI) disorders , Cardiac,
hepatic, or renal disorders
Because xanthine oxidase is a metabolic pathway for uric
acid formation,
Xanthine oxidase is defined as an enzyme activity
Xanthine oxidase is a superoxide-producing enzyme found
normally in serum and the lungs, and its activity is increased
during influenza A infection.[13]
During severe liver damage, xanthine oxidase is released into
the blood, so a blood assay for XO is a way to determine
if liver damage has happened
In 2011, Kozenko et al. reported on a child with multiple
malformations after maternal treatment with allopurinol
throughout pregnancy. Possible teratogenicity of allopurinol
was proposed due to the similarity of the pattern of
malformations in children with mycophenolate embryopathy
Febuxostat : Administer with or without food.
Allopurinol (Zyloprim): Used for prevention of gout
attacks doesn’t relieve an acute attacks
• Most commonly taken with colchicine or NSAIDs.
• Works by decreasing the production of uric acid,
hence preventing gout attacks.
• NURSE’S ROLE: patient needs regular eye exams to
monitor for vision changes and to avoid vitamin C
supplements while taking due to risk for renal calculi
formation.
• Probenecid is a medicine that works for people who
cannot get rid of enough uric acid. It works to remove
extra uric acid through your urine. Probenecid can
increase your risk of kidney stones. Probenecid is not
safe to take for many people with kidney disease, so
talk to your doctor for more information about
probenecid.
Action:
• Xanthine oxidase inhibitors (febuxostat, allopurinal)
inhibit uric acid formation.
• Uricosuric agent (probenecid) accelerates uric acid
excretion.
• Recombinant uric acid oxidase (pegloticase)
promotes uric acid breakdown.
• Colchicine used primarily for patients who do not
respond to other safer agents.
Side Effects:
• Febuxostat (Uloric): nausea, arthralgia, rash, and
abnormal liver function studies
• Probenecid: vomiting, diarrhea, anorexia; renal
deposits of urate may cause damage
• Allopurinol (Zyloprim): GI symptoms, drowsiness,
headache, abdominal cramping; toxicity—
hypersensitivity syndrome with rash, fever,
eosinophilia, and liver and renal malfunction;
prolonged use may cause cataracts
• Pegloticase (Krystexxa): anaphylaxis, infusion
reactions
Nursing Implications
1. Hyperuricemic agents are given to prevent an attack;
are not effective for an acute attack.
2. Initially, symptoms may worsen until uric acid levels
are decreased.
3. Antigout agents can be given with food and milk to
decrease GI discomfort.
4. Teach lifestyle changes—controlling weight, limiting
alcohol consumption, limiting meals with meats and
fish rich in purines, increasing low-fat dairy
consumption, and consuming cherries.
5. Encourage an increased intake of fluids to increase
excretion of uric acid and to decrease concentration.
Bisphosphonate
Actions:
 inhibits bone resorption by decreasing activity of
osteoclasts;
 provides significant increase in bone mineral density
Uses: Prevents and treats the progression of osteoporosis in
postmenopausal women
Resorption - he process by which osteoclasts break down the
tissue in bones[1] and release the minerals, resulting in a
transfer of calcium from bone tissue to the blood.[2]
Is a type of bone cell that breaks down bone tissue?
Side Effects • Oral medications—esophagitis, GI irritation and
discomfort, back pain
Use to a decrease in estrogen production after menopause,
women's bodies are less able to retain calcium from dietary
sources. Calcium supplementation has been used for
decades to prevent this calcium depletion, maintain bone
mass, and prevent and treat osteoporosis.
We conclude that estrogen treatment
increases calcium absorption in postmenopausal osteoporosis
by increasing serum 1,25(OH)2D. This effect appears to be
mediated indirectly through stimulation of renal 1 alpha-
hydroxylase by increased serum PTH
Contraindications and Precautions

• Gastrointestinal (GI) irritation, esophageal disease,

gastroesophageal reflux disease (GERD), and renal function
impairment

• Patients with swallowing disorders

• Orange juice, coffee, or food significantly decreases

effectiveness.

• After taking medication, patient should remain upright

(sitting or standing) for 30 to 60 minutes. Patient
should not lie down until after eating.

• Patient should not take medication at bedtime or at

the same time as other medications (including aspirin,
antacids, or calcium supplements).

Side effects of the oral tablets may include nausea, difficulty

swallowing, heartburn, irritation of the esophagus (tube
connecting the throat to the stomach) and gastric ulcer. When
low levels of calcium in the blood are
present, bisphosphonates should not be given