Pharmacy Review: Osteoarthritis: The Pharmacist's                Perspective

OBJECTIVE: To review new pharmacologic agents approved for use in the management of rheumatoid arthritis (RA). DATA SOURCES: A MEDLINE search (1966–January 2000) was conducted to identify English-language literature available on the pharmacotherapy of RA, focusing on celecoxib, leflunomide, etanercept, and infliximab. These articles, relevant abstracts, and data provided by the manufacturers were used to collect pertinent data. STUDY SELECTION: All controlled and uncontrolled trials were reviewed. DATA EXTRACTION: Agents were reviewed with regard to mechanism of action, efficacy, drug interactions, pharmacokinetics, dosing, precautions/contraindications, adverse effects, and cost. DATA SYNTHESIS: Traditional pharmacologic treatments for RA have been limited by toxicity, loss of efficacy, or both. Increasing discoveries into the mechanisms of inflammation in RA have led to the development of new agents in hopes of addressing these limitations. With the development of celecoxib, a selective cyclooxygenase-2 inhibitor, the potential exists to minimize the gastrotoxicity associated with nonsteroidal antiinflammatory drugs. Leflunomide has been shown to be equal to or less efficacious than methotrexate, and may be beneficial as a second-line disease-modifying antirheumatic drug (DMARD). The biologic response modifiers, etanercept and infliximab, are alternatives that have shown benefit alone or in combination with methotrexate. However, they should be reserved for patients who fail to respond to DMARD therapy. Further studies should be conducted to evaluate the long-term safety and efficacy of these agents as well as their role in combination therapy. CONCLUSIONS: Celecoxib, leflunomide, etanercept, and infliximab are the newest agents approved for RA. Clinical trials have shown that these agents are beneficial in the treatment of RA; however, long-term safety and efficacy data are lacking.

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Comprehensive Treatment of Dactylitis in Psoriatic Arthritis

The Journal of Rheumatology ◽

10.3899/jrheum.140879 ◽

2014 ◽

Vol 41 (11) ◽

pp. 2295-2300 ◽

Cited By ~ 30

Author(s):

Shawn Rose ◽

Sergio Toloza ◽

Wilson Bautista-Molano ◽

Philip S. Helliwell

Keyword(s):

Psoriatic Arthritis ◽

Primary Outcome ◽

Treatment Options ◽

Current Treatment ◽

Nonsteroidal Antiinflammatory Drugs ◽

Clinical Feature ◽

Comprehensive Treatment ◽

Limited Data ◽

Disease Modifying Antirheumatic Drugs ◽

Antiinflammatory Drugs

Dactylitis, a hallmark clinical feature of psoriatic arthritis (PsA) and other spondyloarthropathies, may also be a severity marker for PsA and psoriasis. Traditionally, clinicians have used nonsteroidal antiinflammatory drugs and local corticosteroid injections to treat dactylitis, although conventional disease-modifying antirheumatic drugs are also used. We performed a systematic literature review to determine the most efficacious current treatment options for dactylitis in PsA. Effect sizes were greatest for the biologic agents ustekinumab, certolizumab, and infliximab, suggesting that therapy with one of these agents should be initiated in patients with dactylitis. However, the limited data highlight the need for randomized, placebo-controlled trials, with dactylitis as a primary outcome, to determine a valid, reliable, and responsive clinical outcome measure for PsA patients with dactylitis.

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Opioid-Sparing Analgesics in Chronic Pain Management

10.2310/anes.15086 ◽

2017 ◽

Author(s):

Maricela Schnur ◽

Michael Fitzsimons ◽

Fangfang Xing

Keyword(s):

Chronic Pain ◽

Treatment Options ◽

Primary Treatment ◽

Opioid Therapy ◽

Nonsteroidal Antiinflammatory Drugs ◽

Prescription Opioid ◽

Antiinflammatory Drugs ◽

Opioid Sparing ◽

Pharmacologic Treatments ◽

Chronic Pain Therapy

Chronic pain impacts the lives of millions of people in significant medical and psychosocial ways. Pharmacologic treatments are steering away from chronic opioid therapy due to serious side effects, an epidemic of prescription opioid abuse, and a lack of clear long-term benefit. Therefore, nonopioid medications such as nonsteroidal antiinflammatory drugs, acetaminophen, tricyclic antidepressants, lidocaine patch, and anticonvulsants are important opioid-sparing or primary treatment options. Agents such as capsaicin, cannabis, botulinum toxin, and ketamine are less frequently prescribed adjuncts that are under active investigation to determine their roles in chronic pain therapy. Understanding the research can help the clinician determine the risks and benefits of these medications for their patients. In the future, dose and delivery optimization, combination therapy, elucidating the biology of pain, and developing novel agents will improve pharmacologic approaches to treatment.

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A randomized, controlled clinical trial of ketoprofen for sickle-cell disease vaso-occlusive crises in adults

Blood ◽

10.1182/blood-2009-06-227330 ◽

2009 ◽

Vol 114 (18) ◽

pp. 3742-3747 ◽

Cited By ~ 36

Author(s):

Pablo Bartolucci ◽

Tony El Murr ◽

Françoise Roudot-Thoraval ◽

Anoosha Habibi ◽

Aline Santin ◽

...

Keyword(s):

Pain Relief ◽

Sickle Cell Disease ◽

Sickle Cell ◽

Controlled Trial ◽

Nonsteroidal Antiinflammatory Drugs ◽

Controlled Clinical Trial ◽

Cell Disease ◽

Antiinflammatory Drugs ◽

Double Blind ◽

End Points

Abstract Vaso-occlusive crisis (VOC) is the primary cause of hospitalization of patients with sickle-cell disease. Treatment mainly consists of intravenous morphine, which has many dose-related side effects. Nonsteroidal antiinflammatory drugs have been proposed to provide pain relief and decrease the need for opioids. Nevertheless, only a few underpowered trials of nonsteroidal antiinflammatory drugs for sickle-cell VOC have been conducted, and conflicting results were reported. We conducted a phase 3, double-blind, randomized, placebo-controlled trial with ketoprofen (300 mg/day for 5 days), a nonselective cyclooxygenase inhibitor, for severe VOC in adults. A total of 66 VOC episodes were included. The primary efficacy outcome was VOC duration. The secondary end points were morphine consumption, pain relief, and treatment failure. Seven VOC episodes in each group were excluded from the analysis because of treatment failures. No significant between-group differences were observed for the primary outcome or the secondary end points. Thus, although ketoprofen was well-tolerated, it had no significant efficacy as treatment of VOC requiring hospitalization. These findings argue against its systematic use in this setting.

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Opioid-Sparing Analgesics in Chronic Pain Management

10.2310/pm.15086 ◽

2017 ◽

Author(s):

Maricela Schnur ◽

Michael Fitzsimons ◽

Fangfang Xing

Keyword(s):

Chronic Pain ◽

Treatment Options ◽

Primary Treatment ◽

Opioid Therapy ◽

Nonsteroidal Antiinflammatory Drugs ◽

Prescription Opioid ◽

Antiinflammatory Drugs ◽

Opioid Sparing ◽

Pharmacologic Treatments ◽

Chronic Pain Therapy

Chronic pain impacts the lives of millions of people in significant medical and psychosocial ways. Pharmacologic treatments are steering away from chronic opioid therapy due to serious side effects, an epidemic of prescription opioid abuse, and a lack of clear long-term benefit. Therefore, nonopioid medications such as nonsteroidal antiinflammatory drugs, acetaminophen, tricyclic antidepressants, lidocaine patch, and anticonvulsants are important opioid-sparing or primary treatment options. Agents such as capsaicin, cannabis, botulinum toxin, and ketamine are less frequently prescribed adjuncts that are under active investigation to determine their roles in chronic pain therapy. Understanding the research can help the clinician determine the risks and benefits of these medications for their patients. In the future, dose and delivery optimization, combination therapy, elucidating the biology of pain, and developing novel agents will improve pharmacologic approaches to treatment.

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Treatment of Levator Ani Syndrome with Cyclobenzaprine

Annals of Pharmacotherapy ◽

10.1345/aph.1r144 ◽

2012 ◽

Vol 46 (10) ◽

pp. 1440-1440 ◽

Cited By ~ 7

Author(s):

Maheen Sheikh ◽

Crystal A Kunka ◽

Ken S Ota

Keyword(s):

Motor Neurons ◽

Treatment Options ◽

Levator Ani ◽

Nonsteroidal Antiinflammatory Drugs ◽

Antiinflammatory Drugs ◽

Electrogalvanic Stimulation ◽

Anorectal Pain ◽

History Of ◽

The Central Nervous System ◽

Levator Ani Syndrome

Objective TO report a case of levator ani syndrome (LAS) that was successfully treated with cyclobenzaprine. Case Summary A 26-year-old male presented with a 3-week history of severe, intermittent, aching anorectal pain that would last for 30–60 minutes per episode and occurred between 1 and 3 times per day. The pain was aggravated by squatting, with no alleviating factors. Physical examination revealed no prostate tenderness, lesions, hemorrhoids, or fissures and rectal tone was intact. The patient had moderate posterior rectal tenderness. After a standard workup, he was diagnosed with LAS and treated with oral cyclobenzaprine 5 mg 3 times daily for 7 days. The patient experienced resolution of his symptoms after 3 days of treatment and remained symptom-free 6 months after completion of therapy. The only reported adverse effect was mild drowsiness, which resolved after discontinuation of the cyclobenzaprine. Discussion A review of the literature via StatRef (April 1965-December 2011), Ovid (April 1965-December 2011), and MEDLINE (April 1965-December 2011) reveals that existing treatment options for LAS have been limited to levator massage, sitz baths, nonsteroidal antiinflammatory drugs, diazepam, biofeedback, botulinum toxin, steroid injections, and electrogalvanic stimulation, all of which offer minimal support. Cyclobenzaprine is a muscle relaxant; however, its mechanism of action is unclear. It is thought to influence the α and γ motor neurons in the central nervous system, which leads to the attenuation of muscle spasm. To our knowledge, cyclobenzaprine has not been reported as a treatment for LAS. In our patient, however, the clinical efficacy of cyclobenzaprine was clearly apparent. Conclusions Cyclobenzaprine effectively treated our patient's LAS. Given that cyclobenzaprine is safe, inexpensive, and shown to be effective in our case study, we believe it warrants further investigation as a first-line treatment option for LAS.

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Opioid-Sparing Analgesics in Chronic Pain Management

10.2310/cannabis.15086 ◽

2017 ◽

Author(s):

Maricela Schnur ◽

Michael Fitzsimons ◽

Fangfang Xing

Keyword(s):

Chronic Pain ◽

Treatment Options ◽

Primary Treatment ◽

Opioid Therapy ◽

Nonsteroidal Antiinflammatory Drugs ◽

Prescription Opioid ◽

Antiinflammatory Drugs ◽

Opioid Sparing ◽

Pharmacologic Treatments ◽

Chronic Pain Therapy

Chronic pain impacts the lives of millions of people in significant medical and psychosocial ways. Pharmacologic treatments are steering away from chronic opioid therapy due to serious side effects, an epidemic of prescription opioid abuse, and a lack of clear long-term benefit. Therefore, nonopioid medications such as nonsteroidal antiinflammatory drugs, acetaminophen, tricyclic antidepressants, lidocaine patch, and anticonvulsants are important opioid-sparing or primary treatment options. Agents such as capsaicin, cannabis, botulinum toxin, and ketamine are less frequently prescribed adjuncts that are under active investigation to determine their roles in chronic pain therapy. Understanding the research can help the clinician determine the risks and benefits of these medications for their patients. In the future, dose and delivery optimization, combination therapy, elucidating the biology of pain, and developing novel agents will improve pharmacologic approaches to treatment.

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Drug-Induced Photosensitivity: A Clinical Review

Journal of Pharmacy Technology ◽

10.1177/875512259601200204 ◽

1996 ◽

Vol 12 (2) ◽

pp. 52-57

Author(s):

Stacey Beasley ◽

Oscar E Araujo ◽

Franklin P Flowers

Keyword(s):

English Language ◽

Data Extraction ◽

Treatment Options ◽

Coal Tar ◽

Nonsteroidal Antiinflammatory Drugs ◽

Hypoglycemic Agents ◽

Thiazide Diuretics ◽

Antiinflammatory Drugs ◽

Drug Induced ◽

Study Selection

Objective: To provide an overview of drug-induced phototoxic and photoallergy reactions, the mechanism involved, and the most common classes of drugs causing these reactions. Data Source: Pertinent English-language literature (1987–1993). Study Selection: Representative articles documenting mechanisms and types of drug-induced photosensitivity reactions, as well as treatment options. Data Extraction: Data were extracted only from articles that documented relevant and substantive information backed by clinical studies. Data Synthesis: Drug-induced photosensitivity can be acute or chronic. The chromophore that absorbs the radiation and activates the process of photosensitivity results in color within the longer ultraviolet wavelength. The primary classes of drugs causing phototoxic reactions include nonsteroidal antiinflammatory drugs, thiazide diuretics, tetracycline, and quinolone antibiotics, tricyclic antidepressants, and amiodarone. Those causing photoallergic reactions include antihistamines, thiazide diuretics, sulfonamides, griseofulvin, sulfonylurea hypoglycemic agents, benzocaine, and coal tar preparations. Conclusions: The importance of understanding the mechanism of photosensitivity is stressed as well as the difficulty in determining whether a phototoxic or photoallergic reaction has occurred. Established classes of each type of photosensitivity are identified and the importance of recognizing treatment options is emphasized. Patients prone to photosensitizing reactions should be advised concerning how to manage these problems.

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Cancer Pain Management in Ambulatory Patients

Journal of Pharmacy Practice ◽

10.1177/089719009500800602 ◽

1995 ◽

Vol 8 (6) ◽

pp. 260-268

Author(s):

Linda R. Bressler

Keyword(s):

Pain Management ◽

Pain Relief ◽

Cancer Pain ◽

Physical Dependence ◽

Opioid Analgesics ◽

Drug Dose ◽

Nonsteroidal Antiinflammatory Drugs ◽

Cancer Pain Management ◽

Antiinflammatory Drugs ◽

Selection Of

Pain, by definition, is a subjective phenomenon. The subjective component in chronic pain due to cancer is very important. Opioid analgesics are the mainstay of treatment for cancer pain. Their use should be optimized to provide adequate pain relief. Optimal use includes understanding the concepts of tolerance, physical dependence, and psychological dependence. None of these should limit or inhibit pain management. Optimal use also includes familiarity with the clinical use of opioids. Regular use is generally preferred over “prn” use. Increased parenteral versus oral effectiveness of opioids, secondary to a high first-pass effect, is an important consideration when routes of administration must be altered. Familiarity with approximate equianalgesic doses allows for conversion from one opioid to another. Such conversion might help increase the convenience, increase the efficacy, or decrease the adverse effects of an opioid regimen. Knowledge of durations of action of opioids helps in the selection of dosing intervals to facilitate continuous pain relief. Morphine is the most common opioid chosen for cancer pain management, but others may be equally effective. Follow-up assessments with subsequent alterations are as important as the initial selection of drug, dose, and dosing interval. Adjuvant analgesics, such as nonsteroidal antiinflammatory drugs, anticonvulsants, or antidepressants, may enhance pain relief, especially in certain pain syndromes (eg, metastatic bone pain, neuropathic pain). These agents are usually used in addition to opioids.

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Treatment Response and Longterm Outcomes in Children with Chronic Nonbacterial Osteomyelitis

The Journal of Rheumatology ◽

10.3899/jrheum.161255 ◽

2017 ◽

Vol 44 (7) ◽

pp. 1058-1065 ◽

Cited By ~ 30

Author(s):

Anja Schnabel ◽

Ursula Range ◽

Gabriele Hahn ◽

Reinhard Berner ◽

Christian M. Hedrich

Keyword(s):

Treatment Initiation ◽

Treatment Options ◽

Retrospective Chart Review ◽

Chronic Recurrent Multifocal Osteomyelitis ◽

Nonsteroidal Antiinflammatory Drugs ◽

Antiinflammatory Drugs ◽

Tertiary Referral Center ◽

Tnf Α ◽

Relapse Rates ◽

Chronic Nonbacterial Osteomyelitis

Objective.The autoinflammatory bone disorder chronic nonbacterial osteomyelitis (CNO) covers a wide clinical spectrum, ranging from mild self-limited presentations to chronically active or recurrent courses, which are then referred to as chronic recurrent multifocal osteomyelitis (CRMO). Little is known about treatment options and longterm outcomes. We investigated treatment responses and outcomes in children with CNO.Methods.A retrospective chart review was conducted in a tertiary referral center, covering 2004–2015. Disease activity was measured at 0, 3, 6, 12, and 24 months after treatment initiation, and at the last recorded visit.Results.Fifty-six patients with CNO were identified; 44 had multifocal CNO. Fifty percent of patients relapsed after a median of 2.4 years, and as few as 40% remained relapse-free after 5 years. Nonsteroidal antiinflammatory drugs were used as first-line treatment in 55 patients, inducing remission after 3 months in all individuals with relapse rates of 50% after 2 years. Further treatment included corticosteroids (n = 23), tumor necrosis factor-α (TNF-α) inhibitors (n = 7), and bisphosphonates (n = 8). While 47% of patients with CNO relapsed within 1 year after corticosteroid therapy, favorable outcomes were achieved with TNF-α inhibitors or bisphosphonates (pamidronate).Conclusion.CNO is a chronic disease with favorable outcomes within the first year, but high relapse rates in longterm followup. Particularly, patients with CRMO with long-lasting, uncontrolled inflammation were at risk for the development of arthritis. Our findings underscore the importance of a timely diagnosis and treatment initiation. Prospective studies are warranted to establish evidence-based diagnostic and therapeutic approaches to CNO.

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