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Rheumatoid (part 12) | Management (C) | Hydroxychloroquine and other Synthetic DMARDs

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­čśŹ­čľ╝Animated Mnemonics (Picmonic):

Hates miracles as perfection elsewhere medicine just makes perfect sense we continue our series and rheumatology this is the video about rheumatoid management they will talk about the synthetic d mods so let’s get started how do you diagnose rheumatoid arthritis as they say in new york it’s complicated first the symptoms have to be there for more than six weeks

Clinically you need history and physical exam you need to go to the lab to get some stuff joint fluid analysis you just tap the joint and aspire to the fluid and take it to the lab radiology so of course you need imaging and you will see symmetrical involvement of joints of course it’s polyarticular not mono articular if it’s symmetrical by definition it’s not mono

Articular duh tissue biopsy you can do it but it’s rarely done because it’s freakin invasive and mr. hippocrates once said to us do no harm treatment of rheumatoid arthritis medical or surgical medical non-steroidals steroidal czar here with other immune suppressants and the de morn’s today’s topic is that synthetic demons because as you know demons are divided

Into synthetic and non-synthetic holes known as biological team arts or the biologics and then the biologics are subdivided into tnf or non tnf inhibitors note number one do combine more than one medication progressed just very very cool so you can combine a non-steroidal with a freakin methotrexate but never ever ever combine more than one biologic do not do that

Do not do not in the past we used to treat rheumatoid arthritis based on the symptoms mild symptoms gets you maltreatment moderate symptoms moderate treatment severe some aggressive but now we go aggressive from the beginning why because we realize that remission of rheumatoid can happen remission like the disease which goes away yes indeed something that was

Unheard of fifty years ago thanks to the amazing freakin dmards especially the biological dmards which we’ll discuss later so how should i first you should diagnose it confirm the diagnosis then start the des mots right away and then you adjust the treatment later you might remove methotrexate you might increase the dose decrease the dose substitute substitute

The treatment etc i have a beautiful table comparing between aspirin and other nonsteroidals at slash medic osis and i have another more beautiful table comparing between non-selective cox inhibitor and selective cox-2 inhibitors such as the famous silicic set these are the ten rules for the treatment of rheumatoid arthritis we have discussed that

Before so today’s topic is the synthetic demars they are conventional they are none biologics they are chemicals not derived from cell proteins the biological or logical so they are derived from cell proteins that’s why we call them biological the synthetic include many including methotrexate sulfasalazine hydroxychloroquine lilou an amide etc etc etc why the

Flip do you call them dmards because they are disease-modifying antirheumatic drugs but do not say they are anti rheumatic fever no no they are anti-roman toid arthritis and there is a big difference between rheumatic and rheumatoid roommate oh it has the word void which means like it’s like romantic but it’s not rheumatic it’s rheumatoid it’s like the famous

Operating system for mobile phones called android and ro means man and o it means like it’s like a man because it’s a robot now shame on you if you carry an android device and you did not know that the team arts are powerful man okay but there are no solutions in life that are only trade-offs said the great dr. thomas so what’s the trade-off the treat of day they

Take weeks or months to start to work the onset is delight so what’s that solution again there are no solutions there are trade-offs ad non-steroidals or steroids to bridge the gap and tell those dmards kick into gear brilliant here is a list of the synthetic diamonds they are conventional they are non biological they are chemicals they are not derived from the

Soul proteins hence synthetic they include gold penicillamine sulfasalazine methotrexate laughs lewin amide hydroxychloroquine a sapphire print cyclosporine a cyclophosphamide mycophenolate mojito and two fet two facet in the bo name these things tinna again tenable like imatinib oh it’s a jak kinase inhibitor imagine my shock now let’s have some fun synthetic

Demos 1 & 2 are no longer used gold is history why because it’s a bad investment ha ha if you have invested $1 in gold in the year 1800 1 do you know what would it be worth in the year 1998 the answer is 78 cents you have lost money in nominal terms not to mention in real terms when you adjust for inflation hope you like your stupid investment so it’s just a

Horrible investment do you think it’s gonna be a great mitigation shut up it’s not number 2 penicillamine it’s called penny it’s the penny destroyed by inflation forget it i do not give investment advice i mean get your head out of your sphincter so for sale rosine so 4000 is the southern do you wanna know why sulfasalazine is the southern watch my next video is

Gonna be a mnemonic on sofas lv if methotrexate thf is a myth forget it it’s history lifts lune amide it’s the leave that comes in front of a pyramid because it’s a pyrimidine inhibitor got it hydroxychloroquine is the african queen why african because malaria is common in africa but this african queen went blind because hydroxychloroquine is toxic to your retina

The last one is a sofia brain is a thiopurine rule of big toe i mean the thumb they are all fail and genes to me mild rheumatoid arthritis you give hydroxychloroquine moderate to severe rheumatoid arthritis you give methotrexate that’s an exam question take it to the bank comes in every exam methotrexate we prefer to use it for rheumatoid arthritis especially if

It’s moderate to severe but it has side effects oh yeah do you know like clean water drink too much of it and you will you don’t get sick you’ll get the same symptoms as a with siadh there are no solutions in life there are trade-offs sulfasalazine is the number one anti-drug in europe but in the united states its methotrexate it’s used in rheumatoid and inflammatory

Bowel disease side-effects include all the gasper mia reversible thank heavens let’s talk about self a scelzi it’s divided into two components like the same drug contains two different categories or two different compounds the sulfa pyro diene component and the five amino silicic acid component the sulfa pyridine component treats the rheumatoid arthritis why because

It gets absorbed in your gi tract and goes to your blood so the sulfa is systemic that’s a mnemonic the five asc on the other hand is a local it stays in the gi tract and it acts as a local non-steroidal anti-inflammatory drug that’s why it’s a great treatment for inflammatory bowel disease because i do not know if you have heard inflammatory bowel disease affects

Your bowel okay so it stays in the gi trades the ibd side-effects of self appeared ensign says the word sulfite has sulfur component it can cause allergy in patients with sulfur drug allergy also you should check the g6pd enzyme level before you initiate the treatment because it can cause acute hemolytic anemia in patients with g6pd deficiency if the patient is

Allergic to aspirin please do not give sulfasalazine why not because have you noticed it’s a local non-steroidal and aspirin is a non-steroidal like think people self-assessing decreases folate absorption which is really bad why because it can lead to megaloblastic anemia without neurological symptoms because this is folate this is not b12 neural tube defects in

The embryos give mama a lots of folic acid please to keep the baby healthy by the way this great slide came from my antibiotics course where i’ve talked about sulfonamides same freakin concept okay mother kosis but how do i get your antibiotic scores here is how you get a jeffrey you go to kosis perfectionist come enter the promo code antibiotic 62 received a 60%

Discount towards my course and this is available only until the end of january 2020 thank you so much jeffrey now forget about the first two the our history let’s conquer the rest one by one we discuss alpha cells in a let’s turn our attention to the hydroxychloroquine the african queen who went blind hydroxychloroquine remember the african queen who went blind

Because hydroxychloroquine is toxic to your retina okay why should we use it for mild rheumatoid and lupus it works better for lupus than for rheumatoid hydroxychloroquine is a proud member of the quinine family you can give hydroxychloroquine alone although you can combine it in a famous combo which is more expensive than any combo at mcdonald’s methotrexate

Plus hydroxychloroquine plus sulfasalazine side effects retinopathy the risk increases if the patient had hepatica renal insufficiency because they cannot eliminate hydroxychloroquine efficiently is hydroxychloroquine safe in pregnancy yes it is okay meera kosis you told us about true there is an amputee with like can you be more specific yes it’s pigment harry a

Retinitis what does itis means inflammation of the retina with pigments so before you start the freakin hydroxychloroquine you do baseline ophthalmological exam okay dear patient before i start you on this drug i would like you to get an ophthalmology collegues am okay fine we got it record it and keep it in the record then prescribe hydroxychloroquine and then you

Do the i exam you repeat it annually and then you compare it to the previous one and then what do you mean by annual eye exam i need an optical coherence tomography and a visual field testing in the good old days which were not so good we use the confrontation test also known as the gross confrontation test gross means big not disgusting but now thanks to technology

We have the perimetry test are there other side effects this dadgum hydroxychloroquine you bet hemolytic anemia speedy deficiency patients skin hyperpigmentation and rash please use sunblock neuropathy it may exacerbate psoriasis myopathy and myo means muscle including your cardiac muscle and skeletal muscle now let’s talk about methotrexate which makes thf a

Freakin myth methotrexate we start with para amino benzoic acid or paba plus starett i’d and then by the dogged rotor weight synthase we get the dog i droped aerobic acid you add some glutamate to get ahead of folic acid or d hf thanks to the hydra force s reductase or dhfr you get the tetrahydrofolate instead of d hf now we have the chf tetrahydrofolate acid

And then the sutra hydrophobic as will become methylene t hf methylene t hf can help you make purines pyrimidines and methionine purines here is a pure diamond pyrimidine here is a nice pyramid because i’m from egypt and methionine which will give you sam here is uncle sam with his nice fancy suit because he spends like his in congress he keeps borrowing money

From himself yeah uncle sam lends money to uncle sam we are stupid back to the pathway so fauna mites can inhibit the toy character weight synthase tmp or pyrimethamine can inhibit dihydrofolate reductase i’ve talked about all of these in my antibiotics course methotrexate inhibits the same step the da hydra folate reductase that’s why tetrahydrofolate is now

A myth it’s history and therefore you cannot make methylene thf you cannot make purine pyrimidine and fine when you cannot make purines and pyrimidines you cannot make dna therefore you cannot replicate if you are a bone marrow you can get bone marrow suppression such as you know anemia thrombocytopenia leukopenia the usual stuff methotrexate we use it orally

Intramuscularly or subcutaneous look at this angle okay why is this represents like why does that represent intramuscular instead of intravenous intravenous is going to be a blue syringe by the way methotrexate is the most common initial demons for rheumatoid arthritis especially if it’s moderate to severe mechanism of action inhibits dihydrofolate reductase

Enzyme their 40s have decreases and you cannot make dna or rna which is great if you are a freaking b lymphocyte because if there is no b lymphocyte there is no plasma cell if there is no plasma cell there are no o2 antibodies to attack your joins that’s why we use methotrexate to treat rheumatoid arthritis side effects include alopecia skin nodules which might

Confuse you with rheumatoid arthritis nodules so you should examine the patient before you prescribe the trek state and after to determine whether it’s coming from methotrexate or not or you can stop the methotrexate temporarily check to see if the skin nodules disappear and then resume bone marrow suppression is a given megaloblastic anemia with high mcv because

It’s anti folate even though it’s a folate analogue interstitial pulmonary fibrosis which will lead to decrease dlco what is dlco what my pulmonology playlists’ i have a video called dlco liver toxicity with high alt and ast it’s teratogenic before you prescribe methotrexate please order a pregnancy test methotrexate can cause me echo situs and pneumonitis they

Come on the exam all the time contraindications to methotrexate use pregnancy so hydroxychloroquine is safe during pregnancy but methotrexate is not it’s contraindicated if the patient has hepatic insufficiency or renal insufficiency or if the patient is a heavy alcoholic because methotrexate is anti folate alcohol is anti foley to anti folates say goodbye o to

Your dna say goodbye to your cell replication and you know what’s gonna happen to you without replication eventually you’ll die some tips before prescribing methotrexate order a chest x-ray because of the pulmonary fibrosis cbc because of the mild suppression and the middle bless academy a cmp hep b and c because of the hepatic toxicity etc during the treatment

Add folate supplements and you can use local foreign rescue i’ve talked about this in detail in my antibiotics course antibiotics such as penicillin and sulfonamide can inhibit the excretion of methotrexate from the kidney which will increase the toxicity of methotrexate because it’s now staying in your system more now we’ll talk about live luna mind the leaf that’s

Coming in front of the pyramid lift low an amide the laiv it inhibits pyrimidine firmly in synthesis inhibitor it’s used as initial diamond when methotrexate cannot be tolerated i cannot tolerate it any more adverse effects include hepatotoxicity diarrhea alopecia weight loss saito pina infections as well as interstitial lung disease go green go hairless go weightless

Go blood cell let’s go immune let’s go breathless not to mention caffeine less not funny lif luna mite is neither safe for pregnancy nor lactation before you start with luna might you should order baseline tests such as x-ray cbc hep b and c serology baseline pregnancy test then you take lafoon amide then you repeat the test honey the flu no mind is just horrible

It’s teratogenic and has an extremely long half-life do you remember there was a drug in cardiology specifically an anti-arrhythmic drug particularly a class three antiarrhythmic which had a notoriously long half-life do you remember the name of the drug if you say mu turr├│n you are perfect what if the patient wants to conceive you should stop a little aluminum

I’d okay and then tell the patient to go have a very shut up it has an extremely long half-life you have to get rid of the flu the flu no my you have to wash it out of the system use cholestyramine wash out for 11 freakin days to eliminate the flu no might last let’s talk about a sofia brain or a sofia purine here is pyrimidine and purine synthesis we start with

Ribose 5-phosphate and then we go to pr p p if you know what is what does pr he’s 10-4 please let me know the answer in the comments and then you can go the pyrimidine pathway or the purine pathway if you go the permitting pathway i have some drugs that can inhibit this pathway methotrexate the famous anti-cancer and anti rheumatoid drug gmp and pyrimethamine tmp

Is antibacterial pyrimethamine is anti-parasitic now let’s go the purine pathway i have the azoth i print that can inhibit you is a fibrin is a prodrug what do you mean by a prodrug it’s a pre drug oh so it’s not active by itself that’s true so it needs to be converted to something active before it can exert any effect yes and this active thing is called 6mo cap to

Purine and now when you have six smoke after purine it can inhibit the purine synthesis that’s why i’ve told you is a fire prone remember is a thiopurine while we are at it you know this pyrimidine synthesis it could be inhibited by the leaf that came in front of the pyramid to know more about trimethoprim pyrimethamine and the luke of war in rescue please get my

Antibiotics course thank you for watching please subscribe and hit the bell and click on the join button you can film in all of these platforms please support me on patreon or paypal here is my email here is my website to get my antibiotics course thank you so much for watching as always be safe stay happy and study hard this is m├ędicos is perfection ellis worm

Medicine makes perfect sense

Transcribed from video
Rheumatoid (part 12) | Management (C) | Hydroxychloroquine and other Synthetic DMARDs By Medicosis Perfectionalis