Menu II

Gout

NSAIDs: Special Indications

Indomethacin

  • Overview:indomethacin
    • indole derivative
    • well absorbed (oral route)
    • substantial plasma protein binding
    • hepatic metabolism
    • inactive metabolites & unchanged parent compound: excreted in bile and urine

return to main menu I - return to main menu II

  • Clinical Uses:indomethacin
    • not recommended for analgesia
    •  not recommended for use in children, except:
      •   treatment of patent ductus arteriosus in premature infants
      • prostaglandin production keeps the structure open;accelerated closure, in a premature newborn can be accomplished by intravenous infusion of indomethacin
        • may avoid surgery
        • renal toxicity may occur
      • COX-I dependent
    • Effective in clinical management of:
      • acute gouty arthritis
        • may replace colchicine in initial treatment
        • ankylosing spondylitis
        • extra-articular inflammation, e.g.:
          • pericarditis
          • pleurisy
          • Bartter's syndrome
    •  Controversial Use: tocolytic in preterm labor < 32 weeks gestation
      • Rationale: reduced prostaglandin synthesis ® reduced strength/frequency all of uterine contractions
      •  Difficulty: fetal/maternal drug toxicity
      • Alternative Medication: calcium channel blockers

return to main menu I - return to main menu II

  •  Adverse Effects:indomethacin
    •  at higher dosages: about 33% have reactions sufficient to require withdrawal of indomethacin
    • Gastrointestinal disturbances:
      •  abdominal pain
      •  GI hemorrhage
      •  pancreatitis
      •  diarrhea
    •  Headache common: frequency = 15%-25% (including dizziness, depression, confusion)
    • Hyperkalemia, secondary to renal prostaglandin synthesis inhibition
    •  Contraindicated in patients with:
      • nasal polyps
      • angioedema
      • asthma
      • pregnancy
    •  Cautious Use: -- peptic ulcer disease; psychiatric disorder

return to main menu I - return to main menu II

Phenylbutazone

  • Properties:phenylbutazone
    • pyrazolone derivative
    •  Hematologic toxicities: ® withdrawal from North American markets
      • agranulocytosis/aplastic anemia ® deaths
      • hemolytic anemia
      • many other non-hematologic toxicities

return to main menu I - return to main menu II

 Ketorolac

  • Properties:Ketorolac
    • intermediate duration NSAID
    • marketed for analgesia; not for inflammation (but has typical NSAIDs' properties)
    • Significant analgesic effects --sufficient to replace morphine in mild/moderate post surgical pain
    • parenteral administration route most common
    • ophthalmic preparation available

return to main menu I - return to main menu II

  • Clinical Pharmacological Issues:NSAIDs
    • NSAIDs:less gastric irritation; easier dosing schedule, e.g. better patient compliance
    • NSAIDs: safer than aspirin, more expensive
    •  NSAIDs: gastric ulceration patients taking anti-inflammatory doses --
      • approaches to reduce gastric irritation leading to ulceration:
        •  concurrent administration of misoprostol
        •  misoprostol (prostaglandin E1 analog) reduces (a) gastric acid secretion and (b) the increases gastric mucosal protective factors, e.g. bicarbonate
    •  NSAIDs: increased incidence of acute renal failure; nephrotic syndrome
      •  insidious development
      •  not dose-dependent; not related to drug use duration
    • NSAIDs -- Prescribing Decisions:
      • cost
      • adverse effects
      • dosing schedules-- patient compliance issues
        • once a day/twice a day dosing:
          • piroxicam
          • naproxen
          • sulindac
          • oxaprozin
      • For patients taking hypoglycemic agents or warfarin:
        • ibuprofen--no potentiation of hypoglycemic/warfarin effects
        • tolmetin--no potentiation of hypoglycemic/warfarin effects

return to main menu I - return to main menu II

Disease Modifying Antirheumatic Drugs (DMARDs)

Disease Modifying Antirheumatic Drugs (DMARDs)
methotrexate azathioprine penicillamine hydroxycholoroquine
chloroquine organic gold compounds sulfasalazine

return to main menu I - return to main menu II

return to main menu I - return to main menu II

return to main menu I - return to main menu II

Methotrexate: as a disease modifying antirheumatic drug

return to main menu I - return to main menu II

  • Other immunosuppressive drugs that had been used for treating arthritis:
    • mechlorethamine
    • cyclophosphamide
    • chlorambucil
    • azathioprine -- purine antagonist -- FDA-approved for rheumatoid arthritis  infrequent use due to toxicities: hematologic, hepatic, possible increased incidence of non-Hodgkin's lymphoma).

return to main menu I - return to main menu II
Primary Reference: Katzung, B. G. and Furst, D. E. Nonsteroidal Anti-Inflammatory Drugs; Disease-Modifying Antirheumatic Drugs; Nonopioid Analgesics; Drugs Used in Gout, in Basic and Clinical Pharmacology, (Katzung, B. G., ed) Appleton-Lange, 1998, pp 578-602.
Lipsky, P.E. Rheumatoid Arthritis, In Harrison's Principles of Internal Medicine 14th edition, (Isselbacher, K.J., Braunwald, E., Wilson, J.D., Martin, J.B., Fauci, A.S. and Kasper, D.L., eds) McGraw-Hill, Inc (Health Professions Division), 1998, pp 1880-1888.
Agudelo, C.A. Gout in Medicine for the Practicing Physician, Fourth edition, (Hurst, J. Willis, editor in chief) Appleton & Lange, 1996, pp 223-226.