1. 29
Drugs Used to Treat Musculoskeletal Conditions

2. Multimedia Directory Slide 6 Osteoporosis Video
Slide 25 Arthritis Video
Slide 38 Mechanism of Action of Methotrexate Animation

3. Figure 29-1 The skeletal system and its functions.

4. Calcium Most abundant mineral in body
Proper balance and interaction with other minerals and hormones is essential to optimal function of several body system.
Typical body has 1–2 kg of calcium, 99% of which is in bones.

5. Osteoporosis Bones become thinner and weaker during aging: osteopenia
Osteoporosis: bone mass is reduced enough to cause abnormal functioning
Increased incidence of fracture
Occurs more often in women than men, often in postmenopausal women because of reduced estrogen levels

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7. Table 29-1 Drugs Used to Treat Osteoporosis

8. Bisphosphonates: Uses
Highly selective inhibitor of bone demineralization and resorption; appears to increase bone density
Used to treat osteoporosis; some for Paget’s disease; some for hypercalcemia of malignancy; some for postmenopausal osteoarthritis

9. Bisphosphonates: Adverse Effects
Bisphosphonates commonly cause various GI upsets, including:
Flatulence
Acid regurgitation
Dysphagia
Gastritis

10. Bisphosphonates: Adverse Effects (conditions)
Other adverse effects include:
Headache
Musculoskeletal pain
Rash

11. Bisphosphonates: Contraindications
Contraindicated in severe renal impairment, hypocalcemia, lactation, pregnancy
Used cautiously in patients with congestive heart failure, hypophosphatemia, liver disease, fever or infection, peptic ulcer

12. Bisphosphonates: Patient Information
Review the correct administration with patients.
Advise patients to report fever accompanied by arthralgia and myalgia.
Instruct patients to take 30 minutes before food, beverages, or other medications.

13. Calcitonin: Uses
Derived from salmon, lowers serum calcium and phosphate levels by action on bones and kidneys; inhibits bone resorption, thereby increasing bone density
Used to treat osteoporosis in postmenopausal women, hypercalcemia, and symptomatic Paget’s disease

14. Calcitonin: Adverse Effects
Headache
Eye pain
Anaphylaxis (reported for human calcitonin only)
Urinary frequency
Chills

15. Calcitonin: Adverse Effects
Chest pressure
Weakness
Nasal congestion
Shortness of breath

16. Calcitonin: Contraindications
Avoid in patients with history of allergy (especially to fish)
Safe use in children, pregnancy, and lactation not established
Cautious use in patients with renal impairment or pernicious anemia

17. Calcitonin: Patient Information
Advise patients to report redness, warmth, or swelling at injection site.
Instruct patients to check with physician before taking OTC preparations such as supervitamins and antacids.

18. DMSO
Dimethyl sulfoxide, known as DMSO, is a topical agent that can help reduce pain and inflammation in various musculoskeletal disorders. Only use under a physician’s guidance.

19. Raloxifene (Evista): Uses
A selective estrogen-receptor modulator (SERM); acts by combining with estrogen receptors to decrease bone resorption and increase bone mass and density
Used to prevent and treat osteoporosis and to reduce risk of breast cancer in postmenopausal women

20. Raloxifene: Adverse Effects
Hot flashes
Migraines and other types of headache
Flu-like symptoms
Vaginal bleeding
Uterine and urinary tract disorders

21. Raloxifene: Adverse Effects
Breast pain
Depression
Insomnia
Dizziness

22. Raloxifene: Contraindications
Contraindicated in women who may become pregnant and in those with venous thromboembolic disease
Not to be used with systemic estrogen replacement therapy
Should be used cautiously with diazepam, lidocaine, and diazoxide

23. Raloxifene: Patient Information
Advise patients to report unexplained calf pain or tenderness.
Instruct patients to avoid prolonged restriction of movement during travel.

24. Rheumatoid Arthritis (RA)
Systemic autoimmune disease that involves inflammation of joint-lining membranes; also affects internal organs
Occurs 2–3 times more often in women (onset usually at ages 40–60)
Joints affected include hands, feet, wrists, spine, shoulders, ankles, and hips

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26. Table 29-2 Disease-Modifying Drugs for Rheumatoid Arthritis

27. Table 29-2 (continued) Disease-Modifying Drugs for Rheumatoid Arthritis

28. Gold Compounds: Uses Mechanism of action not clearly understood
Used to treat active RA

29. Gold Compounds: Adverse Effects
Common: syncope, bradycardia, thickening of tongue, metallic taste in mouth
Serious: thrombocytopenia, leukopenia, aplastic anemia

30. Gold Compounds: Contraindications
Uncontrolled diabetes
Renal or hepatic insufficiency
Hepatitis

31. Gold Compounds: Patient Information
Instruct patients to report adverse effects.
Advise patient to report unusual color or odor of urine, and to avoid contact with anyone who has a cold, has had a recent vaccination, or has been exposed to a communicable disease.

32. Hydroxychloroquine (Plaquenil): Uses
Mechanism of action unclear
Used to treat RA and systemic lupus erythematosus

33. Hydroxychloroquine: Adverse Effects
Common: fatigue, headache, mood or mental changes, anxiety, difficulty focusing or blurred vision, anorexia, nausea and vomiting, abdominal cramps
Serious: retinopathy

34. Hydroxychloroquine: Contraindications
Safety in pregnancy and lactation not established.
Cautious use in patients with hepatic disease, alcoholism, impaired renal function

35. Hydroxychloroquine: Patient Information
Advise patients to follow drug regimen exactly as prescribed and to keep drug out of reach of children.
Instruct patients to get regular eye exams.
Instruct patients to avoid breast feeding.

36. Hydroxychloroquine
Acute or chronic diseases that affect liver architecture or function also affect hepatic metabolism of some drugs.
Elderly patients may therefore have markedly affected drug elimination and need dosage adjustment.

37. Methotrexate (Folex, Mexate): Uses
Folic-acid blocker and immunosuppressant that affects lymphocyte and macrophage function
Used to treat severe psoriasis, psoriatic arthritis, and RA; also to maintain remission in neoplastic disease

38. Mechanism of Action of Methotrexate Animation
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39. Methotrexate: Adverse Effects
Common: GI upset and mouth sores, amenorrhea
Serious: bone-marrow suppression, infertility

40. Methotrexate: Contraindications
Contraindicated in: pregnancy and lactation, men and women of childbearing age, hepatic and renal insufficiency, preexisting blood dyscrasias
Cautious use in patients with infections, peptic ulcer, colitis, poor nutritional status

41. Methotrexate: Patient Information
Advise patients of the dangers of this drug and explain symptoms to immediately report.
Warn patients to avoid alcohol.
Tell patients to avoid sunlight and UV light and to wear sunglasses.

42. Methotrexate
Prolonged use of small doses can lead to hepatotoxicity.

43. Sulfasalazine (Azulfidine): Uses
Locally acting sulfonamide that may exert an anti-inflammatory effect
Used to treat RA, juvenile chronic arthritis, and ankylosing spondylitis

44. Sulfasalazine: Adverse Effects
Common: nausea, vomiting, headache, rash
Serious: anemia, oligospermia, blood dyscrasias, liver injury, allergic reactions

45. Sulfasalazine: Contraindications
Contraindicated in patients with agranulocytosis, intestinal and urinary tract obstruction, or porphyria; pregnancy and lactation
Cautious use in severe allergy or bronchial asthma, hepatic or renal impairment, or in children younger than 6 years

46. Sulfasalazine: Patient Information
Instruct patients that urine and skin may turn orange-yellow.
Women should not breast feed.

47. Gout and Gouty Arthritis
Characterized by crystal deposits in and around joint spaces, leading to acute inflammation of joint
Gout commonly affects men after age 50.
Three manifestations: hyperuricemia, acute gouty arthritis, chronic gouty arthritis

48. Table 29-3 Anti-Gout Medications

49. Colchicine: Uses
Uses: anti-inflammatory agent used to treat gout; inhibits formation of white blood cells
Adverse effects: Common: GI disturbances decreased absorption of vitamin B12
Contraindications: severe cardiac, renal, hepatic, blood, and GI diseases

50. Colchicine: Uses
Patient education: Advise patients to report severe GI symptoms or signs of bone-marrow depression.

51. Colchicine in Elderly Patients
Colchicine must be used cautiously in elderly patients because of its possible adverse GI, cardiac, renal, and hepatic effects.

52. Allopurinol (Aloprim): Uses
Improves solubility of uric acid; used to control chronic, not acute, gout

53. Allopurinol: Adverse Effects
Common: drowsiness, headache, dizziness, nausea and vomiting, abdominal pain
Serious: hepatotoxicity, renal insufficiency

54. Allopurinol: Contraindications
Contraindicated children (except in those with hyperuricemia secondary to cancer and chemotherapy)
Safety in pregnancy and lactation not established.
Cautious use in patients with impaired hepatic or renal function, history of peptic ulcer, lower GI tract disease, and bone-marrow suppression

55. Allopurinol: Patient Information
Advise patients to drink 3 quarts of fluid per day.
Instruct patients to report diminishing urine output, cloudy urine, unusual color or odor to urine, pain or discomfort during urination, itching and rash.
Patients should avoid driving and sun exposure.

56. Uricosuric Agents: Uses
Competitively inhibit renal tubular reabsorption of uric acid to promote its excretion
Used to treat severe attacks of gout

57. Uricosuric Agents: Adverse Effects
GI irritation
Allergic dermatitis
Nephrotic syndrome

58. Uricosuric Agents: Contraindications
Contraindicated in patients with blood dyscrasias and uric-acid kidney stone
Safety in pregnancy, lactation, or in children younger than 2 years not established.
Cautious use in patients with peptic ulcer

59. Uricosuric Acid: Patient Information
Advise patients to drink 3 quarts of fluid per day.
Physicians may advise patients to restrict intake of high-purine foods (organ meats, meat soups, and gravy).

60. Uricosuric Acid: Patient Information
Instruct patients to not stop treatment, or not to take aspirin or OTC medications without consulting physician.

61. Muscle Spasms and Pain
Often associated with traumatic injuries and spasticity from disorders such as cerebral palsy, stroke, or head and spinal cord injuries
Two types of muscle spasms: tonic and clonic

62. Table 29-4 Centrally Acting Muscle Relaxants

63. Table 29-4 (continued) Centrally Acting Muscle Relaxants

64. Centrally Acting Skeletal Muscle Relaxants
Uses: treat local spasms to reduce pain and increase range of motion
Adverse effects: sedation, weakness, fatigue
Contraindications: some contraindicated in liver disease, porphyria, children, pregnancy, lactation

65. Centrally Acting Skeletal Muscle Relaxants
Patient information: avoid alcohol, other CNS depressants. Patients with diabetes must closely monitor glucose levels.