cathy sochasky, bscpharm (fcshp) drug information pharmacist health sciences centre dept. of...

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Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

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Page 1: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

Cathy Sochasky, BScPharm (FCSHP)Drug Information Pharmacist

Health Sciences CentreDept. of Pharmacy

Page 2: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

OBJECTIVESTo discuss the various medications used to

treat the arthritic symptoms of scleroderma.To review the potential adverse

effects/interactions associated with these medications.

To understand the importance of monitoring while on these medications for their effectiveness and potential risks.

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Page 3: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

Introduction to SclerodermaChronic multisystem autoimmune diseaseAlso termed “systemic sclerosis”Sclera – “hard” Derma – “skin”Cause unknownSymptoms, extent of skin/organs affected varies

between patients.No one specific medication to fully control

underlying disease process.Many medications used to manage specific

conditions/symptoms of this disease.

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Page 4: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

DiagnosisComplex, often based on clinical symptomsPhysical exam (hands, knees, joints)Investigations (lab results, X-rays)2 Types: localized (skin), systemic (lung,

kidney, blood vessels & heart)

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Page 5: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

Initial SymptomsMusculoskeletal almost always present in

ScD; degree and type variesArthritic-like which include non-specific

muscle pain (flu-like), joint stiffness/puffiness, impaired hand function

May resemble rheumatoid-like polyarthritis or carpal tunnel syndrome in early stages

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Page 6: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

Management of Musculoskeletal Symptoms – What are the Goals and Therapeutic Options?

Goals:1.Control of pain and joint inflammation 2.Immunosuppression – maintenance3.Prevention of organ damage (organ specific tx) – skeletal muscles, GI tract, kidney, lungs)

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Page 7: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

Management of Musculoskeletal Symptoms – What are the Goals and Therapeutic Options? cont’d

Treatment:-Combination drug treatment for rapid control of the inflammation with maintenance treatment (localized).-May require organ specific treatment (systemic)

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Page 8: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

MedicationsNon Steroidal Anti-Inflammatory Drugs

(NSAIDs)AnalgesicsCorticosteroidsDisease Modifying Anti-Rheumatic Modifying

Drugs (DMARDs) – methotrexateOthers (azathioprine, mycophenolate,

cyclophosphamide)

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Page 9: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

Non Steroidal Anti-Inflammatory Drugs Ibuprofen (Motrin®, Advil®)Naproxen (Naprosyn®)Diclofenac (Voltaren®)Celecoxib (Celebrex®)Ketorolac (Toradol®)

Action: - Reduce inflammation & relieve pain- No difference in effectiveness between these meds demonstrated in studies- However, some patients do respond better to one

than another.- Similar action, should not combine

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Page 10: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

Comparative Dosage Table – Common NSAIDs

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Medication Oral Effective Dosage Range

Diclofenac (Voltaren) Immediate release

50 mg three to four times daily

Diclofenac (Voltaren) Enteric coated

50 mg twice to three times daily or 75 mg twice daily

Diclofenac (Voltaren) Extended-release

75 to 100 mg once or twice daily

Ibuprofen (Motrin) 300 mg four times daily; or 400, 600 or 800 mg three to four times daily, not to exceed 3200 mg daily

Ketoprofen (Orudis) 150 to 300 mg daily, given in 3 to 4 divided doses

Naproxen (Naprosyn) 250 to 500 mg twice daily, not to exceed 1500 mg/day

Naproxen Sodium (Anaprox) 275 mg twice daily

Sulindac (Clinoril) 150 mg twice daily, not to exceed 400 mg daily

Tolmetin (Tolectin) 400 mg three times daily, not to exceed 1800 mg daily. Control is usually achieved at doses of 200 to 600 mg daily three times daily

Page 11: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

To take with food or milk – Does it matter?

Most mfrs say to take NSAIDs with food or milk.Rationale – protective effect to stomach(FACT: never been studied to prove it)

Food can delay onset of its effect (only important if immediate relief needed)

Taking an NSAID on an empty stomach is not a risk for GI bleeding to occur.

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Page 12: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

Adverse Effects of NSAIDs

1. GASTROINTESTINAL - Nausea, vomiting, heartburn

- Ulcers, bleeding, perforation

What are the risk factors for GI bleeding/perforation?Long duration of useHigh doses≥ 60 years oldHistory of ulcers/bleedingConcomitant use of alcohol, corticosteroid and/or blood thinners

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Page 13: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

RecommendationAll patients with ≥ 1 of the above risks should:Use a low NSAID doseTake NSAID intermittently Avoid if possibleIf NSAID used, add a protective agent (omeprazole, pantoprazole) or use celecoxib

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Page 14: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

What are the symptoms of GI bleeding? Can occur without warningBlack, tarry stoolsDark specks or blood in vomitWeakness, short of breath, pale skin, stomach pain

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Adverse Effects of NSAIDs cont’d

Page 15: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

2. Cardiac ToxicityDue to their mechanism of action and possibly due to blood pressure elevating effectsIf high blood pressure (BP), should have BP checked prior to and after 1-4 weeks of NSAID use.Note: Pain can increase BP, therefore NSAID use may also lower BP.Risk may be less with naproxen.

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Adverse Effects of NSAIDs cont’d

Page 16: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

3. Kidney effectsConcern re: Scleroderma renal crisis (kidney failure due to hypertension)Monitoring kidney function, blood pressure and electrolytes important in 1st 1-3 weeks and then every 3-6 months if prolonged use.

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Adverse Effects of NSAIDs cont’d

Page 17: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

Other AnalgesicsAcetaminophen (with & without codeine)May be useful for mild arthritic-like painDoes not relieve redness, stiffness or swellingLarge doses may lead to liver damage

Recommend no greater than 3-4 g/day (i.e. 6-8 Tylenol extra strength)

Avoid taking multiple meds that contain acetaminophen eg. OTC cough/cold meds

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Page 18: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

Corticosteroids (e.g. oral prednisone, topical, injections- Depo Medrol®)

Rapid effect on inflammationUsed initially for its possible beneficial effect

on inflammation for arthritis, myositis, puffy hands, skin & lung disease

Used in low doses (≤ 7.5 mg) for short periods, often in combination

Concerns: limited data, side effects (increased risk of renal crisis, serious infections)

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Page 19: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

DMARD- Methotrexate (oral, inj)immunosuppressive used in early stages of

skin, muscle and joint involvementoften in combination with steroidsAdvantages: weekly dosing, low cost, long

standing safety profileDisadvantages: GI symptoms (nausea, flu-like,

oral ulcers, fatigue), drug interactions, frequent blood monitoring

Dosing: Oral dose titrated to maximum of 25-30 mg once a week. (Inj used if not tolerating or oral not effective) Continue 2 mos, up to 4-6 mos

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Page 20: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

Hydroxychloroquine- an oral alternative if intolerance or contraindication to MTX e.g. liver disease

ARE SERIOUS INFECTIONS A RISK WITH MTX?

Not really an issue with the low doses of this drug

May be due to disease itself or use of steroids

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DMARD

Page 21: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

DRUG INTERACTIONS1. NSAIDs + MTXnot a problem with low doses (7.5-15 mg/wk) Concern with higher doses like 150 mg

2. NSAIDs + gingko (herb) Case reports-potential for increased bleeding; use with caution or avoid

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Page 22: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

DRUG INTERACTIONS cont’d

3. NSAIDs and SSRI antidepressants(e.g. citalopram, sertraline, fluoxetine)

increase in upper GI bleeding, main concern in those already at risk of bleedingalternatives: acetaminophen, celecoxib orswitch to different class of antidepressant oradd a drug that protects stomach (e.g. PPI)report to doctor any evidence of bleeding or if going to surgery

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Page 23: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

DRUG INTERACTIONS cont’d

4. MTX and trimethoprim (Septra) Avoid this antibiotic (may affect white blood cells)

5. NSAIDs + BP medications (captopril, valsartan) NSAID may reduce effect of BP medication greatest risk first month dosage adj , monitoring kidney function (esp with diuretics) and BP

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Page 24: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

WEBSITES FOR PATIENT EDUCATION ON ARTHRITIS

www.rheuminfo.comwww.arthritis.ca www.rheumatology.orgwww.arthritis.orgwww.jointhealth.org

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Page 25: Cathy Sochasky, BScPharm (FCSHP) Drug Information Pharmacist Health Sciences Centre Dept. of Pharmacy

QUESTIONS??

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