Drugs Used in Gout and Rheumatic Arthritis for BSc Nursing

1. Drugs for Gout and RA
Dr. Saroj Suwal
The disease of kings" or “Rich man's disease"

2. Gout/Gouty Arthritis
characterized by recurrent attacks of acute
inflammatory arthritis –
a red, tender, hot, swollen joint.
caused by elevated levels of uric acid in the
blood which crystallize and are deposited in
joints, tendons, and surrounding tissues.
• First MTP joint of the big toe is the most
commonly affected (~50% of cases).

3. • metabolic disorder characterized by hyperuricemia
Uric acid → product of purine metabolism,
• normal plasma urate 2–6 mg/dl).
• due to Disorder of Purine metabolism

4. DRUGS FOR GOUT
ACUTE GOUT
• NSAIDS
• Colchicine
• Corticosteroids
CHRONIC GOUT
Uricosurics
• Probenecid
• Sulfinpyrazone
Synthesis Inhibitors
• Allopurinol
• Febuxostat

5. NSAIDS
• Naproxen,
Piroxicam,
Diclofenac,
Indomethacin
Etoricoxib
STRONG
NSAIDS
inhibit
synthesis
of PGs
inhibit
migration
of
leucocytes
into the
inflamed
reduce
inflam
matio
n in
gout.

6. COLCHICINE
• Plant alkaloid from Colchicum autumnale
• suppresses gouty inflammation.
• MOA:
• binds to protein tubulin and inhibits microtubule
formation, arresting granulocyte motility and
decreasing inflammation.
• alsoinhibits leukocyte chemotaxis, formation of
glycoprotein and phagocytosis.

7. Indication:
•Anti-inflammatory in Gout (NSAIDs alternative)
• Chondritis
•Prophylaxis for Gout
• Dose:
• 1mg STAT and then 0.5mg 2-3 hourly until pain
reduces (total 3 doses/day)

8. Adverse effects
•Nausea, Vomiting, Abdominal Pain, Diarrhoea
•Myopathy, Neutropenia, Aplastic anemia,
Alopecia (prolong use)
Contraindications
•Pregnancy
•Liver disease
•Renal disease
•Cardiovascular disease

9. CORTICOSTEROIDS
Cotricosteriods
Inhibit conversion
of phospholipids
into arachidonic acid
suppress inflamtion

11. Routes:
• Oral route
• Intraarticular route
• Intramuscular route
• Intravenous
Orally Prednisolone 40–60 mg may be given in one day,
followed by tapering doses over few weeks.

12. URICOSURICS:
drugs that promote renal clearance of uric acid by
inhibiting urate reabsorption.

13. PROBENECID
Inhibits the
tubular
reabsorbtion of
urate,
increasing the
urinary excretion
of uric acid
decreasing serum
urate level.

14. Indications:
•Chronic Gout & Hyperuricemia
•Prolong the action of Penicillin
•Dose: 250-500mg BD

15. Adverse effect and contraindications
Adverse effects:
• Dyspepsia
• Hypersensitivity (Rashes)
• Gastric distress (Peptic ulcer)
Contraindications:
◦ Should avoid if creatinine clearance is less than 50
ml/min.( normal → 125ml/min)

16. MOA:
Allopurinol is a purine analog which inhibits
the enzyme xanthine oxidase and reduces
ALLOPURINOL

17. Indications
• Hyperuricemia in Gout
• Hyperuricemia in Cancer or Renal diseases
• Kala-azar
Dose:
Start with 100 mg OD, gradually increase as
needed to
300 mg/day; maximum 600 mg/day

18. Adverse effects
• Hypersensitivity (rashes)
• Fever
• Muscle pain
Contraindications
• Pregnancy
• Lactation
• Hypersensiitivity

19. FEBUXOSTAT
MOA:
• is a nonpurine xanthine oxidase inhibitor
• reduces uric acid formation and decreases uric acid
levels in blood.

20. Indications:
• Chronic Gout
• Hyperuricemia Dose: 40-80mg OD
Adverse effects
• Liver damage
• Diarrhoea
• Nausea
• headache
Contraindications
Same as Allopurinol

21. an autoimmune disease in which
there is joint inflammation,
synovial proliferation and
destruction of articular cartilage.
RHEUMATOID ARTHRITIS (RA)

22. Immune complexes
Composed of IgM
Activate complement
release cytokines
(mainly IL6,TNFα and
IL-1, PGE2, Leukotrine
b4)
which are chemotactic
for neutrophils.

23. Goals of Therapy:
•Reduce pain, swelling and joint stiffness.
•Prevent articular cartilage damage and bony
erosions.
•Prevent deformity and preserve joint function.

24. Drugs for Rheumatoid Arthritis
❑ NSAIDS→ first line drugs
❑ CORTICOSTEROIDS→antiinflamatory
and immunosuppresants
❑ DMARDS- Disease Modifying
Antirheumatic Drugs
❑Biologics

25. Disease Modifying Antirheumatoid Drugs (DMARDS)
1.Immunosupressants:
Methotrexate, Azathioprine Cyclosporine
2.Sulphasalazine
3.Hydroxychloroquine
4.Leflunomide
5. TNFα inhibitors:
Etanercept, Infliximab, Adalimumab
6. IL-1 antagonist: Anakinra
Gold & Penicillamine are no longer used!

26. METHOTREXATE : (DMARDS)
Folic acid analog, Antimetabolite
MOA:
• inhibits biosynthesis and
proliferation of DNA and
immune cells (T cell & B cell).
• inhibits cytokine production,
chemotaxis and cell-mediated
immune reaction.

27. Indications:
•First Choice
• alone or combination
•Psoriasis, Ankylosing spondylitis
•Immunosuppression and anti-
inflammatory
•Other uses
• Anticancer (Leukemia, Breast
cancer, Carcinomas)
Dose For Rheumatoid Arthritis:
7.5-15 mg weekly

28. Adverse Effects:
• Bone marrow depression
• Decrease folic acid
• Leukopenia (Decrease WBC)
• Thrombocytopenia (↓ Platelets)
• Anaemia (Decrease RBC)
• Liver damage
• Renal failure
• Skin reactions
• Alopecia
• Ocular irritation
Contraindications:
• Pregnancy
• Bone marrow, Liver And Renal
Impairment
• Ulcerative disorders

29. Why folic acid given with methotrexate?
Methotrexate cause deficiency of Folic acid.
Folic acid is essential for the DNA sysntheis
and cell proliferation
Folic acid deficiency cause→ Anemia,
weakness, oral ulcers, tingling of fingers and
toes, depression, loose appetite
METHOTREXATE inhibits

30. χ

31. SULPHASALAZINE
MOA:
• Anti bacterial
• reduce disease progrssion
• decreases IgA & IgM factors, suppresses T cell
response
• also has anti- inflammatory & immunosuppressive
actions.

33. Cholorquine and
HYDROXYCHLOROQUINE(HCQ)
• Suppress lysosomal enzyme
• Reduce monocyte , IL 1
• Inhibit B lymphocyte and interfere
antigen processing
• Suppress T lymphocytes
• Has free radical activity

34. Indications:
• Rheumatoid Arthritis
• Anti-malarial
Adverse effect
• Retinal damage
• IBS
• Graying of Hair
Dose:
Choloroquine→200mg/day
Dose
Hydroxycholorquine→
• 6.4mg/kg/day
or
• 400 mg/day for 4–6 weeks, followed by 200
mg/day for maintenance
given for long periods of 3-6 months.

35. LEFLUNOMIDE
MOA:
• inhibits proliferation of stimulated
lymphocytes
• Active metabolite of leflunomide inhibits
dihydroorotate dehydrogenase and
pyrimidine synthesis in actively dividing cells
& antibody production by B-cells is
depressed.

36. Indications:
• Rheumatoid Arthritis
• Immunosuppression
Dose:
loading dose of 100 mg daily for 3 days
followed by 20 mg OD.
Adverse effects:
• Loss of hair
• Thrombocytopenia
• Leukopenia

37. BIOLOGICALS
TNFα inhibitors: Etanercept
Infliximab Adalimumab
MOA:
• inhibit cytokines, especially TNFα or IL-1
• are reserve drugs for severe refractory
disease.
• mainly suppress macrophage and T-cell
function.
• Thus inflammation in the joint regress and new
erosions are slowed.
IL-1 antagonist: Anakinra
Abatacept

38. Indications: (given s.c.)
Autoimmune diseases like RA,
inflammatory bowel
diseases, psoriasis, scleroderma, etc.

39. Thank you