Pharmacological Treatments For Arthritis Biology Essay

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Pharmacology means the science of treatment of diseases with drugs. In case of arthritis, there is a variety of prescription and non-prescription medication which aim at relieving the symptoms and arresting the progression of the disease. The commonly-prescribed medications for arthritis can be broadly classified as analgesics (pain killers), disease-modifying anti-rheumatic drugs (DMARDs), biologics, corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs). [1] 

<a>Overview of Options</a>

<b>Analgesics</b>

Suppression of pain is the first step in treating arthritis and many common analgesics are used for this purpose. Analgesics are painkillers which are used for reducing pain although they do not have much impact on other symptoms like inflammation. Disease modifying anti-rheumatic drugs (DMARDs) not only relieve the symptoms of arthritis but help to arrest the progression of the disease. These drugs work by suppressing the effects of the immune system and blocking the chemicals that cause damage to the joints, ligaments and cartilage. Hence the term "disease modifying." DMARDs work slowly and can take four -to six months to act and can have many side effects including mouth ulcers and skin rashes.

<b>Biological Treatments</b>

Biologics comprise a relatively new form of therapy that involves the use of biological response modifiers (BRMs), substances produced naturally in the body in small amounts. They fight infection and disease. Using modern scientific techniques, it is now possible to artificially produce large quantities of BRMs which can be used for treatment of arthritis. Biological drugs act as suppressors of cytokines (substances that trigger the immune system and increase inflammation in the arthritis-affected joints. As with other forms of treatment, biological treatments also cause some side effects such as fever, nausea, skin reactions, and, in rare cases may reactivate some previous ailments such as tuberculosis and hepatitis B.

<b>Corticosteroids</b>

These are manmade (synthetic) drugs that resemble certain hormones produced naturally by the human body. They work by reducing the production of substances that cause inflammation in the body. Corticosteroids are very potent and can provide rapid relief for arthritis pain. However, they have serious side effects and therefore should be used for short periods only. Long term usage of corticosteroids should be done only in very serious cases and under strict medical supervision. Common side effects of these drugs include weight gain, muscle weakness, osteoporosis (weakening of the bones), mood swings, blurred vision, glaucoma or diabetes.

<b>Non-Steroidal Anti-Inflammatory Drugs</b>

NSAIDs work by blocking COX enzymes that are responsible for producing prostaglandins. Prostaglandins are chemicals produced by the human body that are responsible for causing pain and inflammation. By blocking COX enzymes, NSAIDs reduce the levels of prostaglandin in the body, thereby reducing pain and inflammation. These drugs have many side effects that range from problems of the gastrointestinal tract such as nausea, vomiting, heartburn and diarrhea, to more severe conditions such as an increased risk of heart attacks and strokes.

<a>The Debate on Prescription versus Over-the-Counter</a>

<b>Benefits of Prescription Treatment for Arthritis</b>

Prescription treatment [2] for arthritis benefits the patient in two ways. First, medications such as analgesics and NSAIDs provide quick relief from the pain, stiffness and inflammation that accompany arthritis. Corticosteroids also provide fast relief from severe pain and are normally used if the patient is not responding to analgesics or NSAIDs. The second line of therapy involving DMARDs and biological treatments work to arrest the progression of the disease and prevent permanent damage to the joints. A combination of both lines of medication along with other forms of therapy such as proper diet, exercise and self-care can help the patient to remain healthy and active.

<b>Drawbacks of Prescription Treatment for Arthritis</b>

While prescription treatment for arthritis provide much-needed relief from the painful symptoms, it is important to be aware of the risks associated with prescription arthritis medications. Most arthritis medications have side effects that may range from mild skin irritations to a heart attack. For example, strong analgesics such as tramadol or codeine provide pain relief but may cause nausea, confusion or delirium. NSAIDs reduce pain and inflammation but may also attack the digestive system, causing stomach upsets, ulcers and even gastrointestinal bleeding. Corticosteroids provide quick relief but have a number of side effects ranging from weight gain to increase in blood pressure and osteoporosis. DMARDs block the progression of the disease but come with side effects such as mouth ulcers, diarrhea, hair loss, skin rashes and liver problems. Prescription biological drugs also have many side effects, usually skin reactions, nausea, fever and headaches.

The side effects really depend on the drug being used, the frequency and dosage as well as the patient's response to the drug. Even simple over-the-counter (OTC) drugs may have potentially dangerous side effects. Also, certain drugs when taken in combination dramatically increase the risks of side effects. According to a study carried out in Houston, [3] two common arthritis drugs alendronate and naproxen, increase the risk of stomach ulcers when taken together. Also, if a patient is on medication for more than one disease, mixing of medicines may case dangerous side effects. It is therefore very important that all drugs be taken only as prescribed after due consultation with the doctor.

<b>Over-the-Counter and Prescription Medications

Pharmacological treatment for arthritis includes OTC as well as prescription medicines. Over the counter medications do not require a prescription and can be bought off the shelf. Prescription medicines require a doctor's prescription and can be bought only in pharmacies. Prescription medicines are meant only for the person to whom they are prescribed and should never be shared. OTC drugs are generally used for minor pains and are not as strong as prescription medicines. Examples include pain relieving creams and sprays as well as pain relieving drugs like aspirin. Prescription drugs on the other hand are used for the treatment of major arthritis pains and inflammation, and are prescribed by the doctor depending on the severity of the condition. NSAIDs, corticosteroids and DMARDs are prescription drugs.

Arthritis patients may choose OTC or prescription drugs, but even in case of OTC medication, it is still advisable to consult the doctor. This is true primarily for two reasons. First, many OTC drugs have side effects and it is important for the patient to be aware of risks and benefits associated with each drug. Second, while OTC drugs relieve symptoms such as pain and inflammation, they do not stop the progression of the disease. Medical consultation is therefore necessary to take a long-term view of the ailment and provide the necessary medical care before it progresses to an advanced stage.

<a>Disease-Modifying Anti-Rheumatic Drugs</a>

Some DMARDs used for the treatment of arthritis include the following: [4] 

<b>Methotrexate</b>

Methotraxate is a prescription drug used for the treatment of cancer and arthritis. The mechanism of its action against arthritis is not yet fully understood, but it seems to alter immunity. Its side effects include dizziness or drowsiness, nausea, vomiting, sore throat, mouth sores, diarrhea and mild stomach pain. More serious side effects include liver problems, lung infection and tumors.

<b>Sulfasalazine</b>

Sulfasalazine is a prescription drug that reduces pain and inflammation and also prevents joint damage. The mechanism of its action is not yet clearly known. The side effects of sulfasalazine include nausea, vomiting, loss of appetite, mild stomach upsets and skin rashes. In some cases, sulfasalazine has been found to cause abnormalities in liver function, drop in white blood cells, and kidney failure.

<b>Hydroxychloroquine</b>

Hydroxychloroquine is an anti-malarial drug which is also used for the treatment of lupus and rheumatoid arthritis. Although it is not clear how it works, it is thought to have an action on the immune system. Side effects of hydroxychloroquine include skin rashes, nausea, indigestion, headaches and mild hair loss. In very rare cases, it may cause damage to the retina, hence it should be used only as prescribed by the physician.

<b>Leflunomide</b>

A prescription drug, leflunomide works by suppressing the immune cells which cause swelling and inflammation of the joints. The usual side effects include diarrhea, headache, nausea and rashes. Since it suppresses the immune cells, leflunomide can increase the risk of infection. In rare cases, it can also cause liver damage.

<b>Gold Salts</b>

Gold salts are prescription drugs containing gold and are used for the treatment of arthritis. They are believed to block the release of a substance called HMGB1 from the nucleus of body cells. [5] HMGB1 when released from the nucleus affects the immune system and causes inflammation. Common side effects of gold salts are nausea, diarrhea, skin rashes, loss of appetite and mouth sores. More serious side effects include kidney damage and decrease in while blood cells and platelets.

<b>Azathioprine</b>

Azathioprine is a prescription drug. Like other DMARDs, it works by suppressing the immune system, though the exact mechanism of its action is not known. Side effects include nausea and vomiting and loss of appetite. It is also listed as a carcinogen and may cause lymphoma and skin cancer in rare cases.

<b>Cyclosporine</b>

Cyclosporine is a prescription drug. Much like azathioprine, so cyclosporine works by blocking the production of a chemical called cytokine, thereby suppressing the immune system. Its side effects include nausea, vomiting, tremors, headache or body pain and increased hair growth. Serious side effects include kidney damage, liver toxicity, high blood pressure, and increased risk of cancer.

<a>Biological Response Modifiers [6] /Biologic DMARDS<a>

<b>Etanercept</b>

Etanercept is an injectable prescription drug that works by blocking a substance called tumor necrosis factor (TNF) alpha which causes pain and inflammation. The common side effects of this drug are headache, dizziness and skin and throat irritation. Since this drug works by suppressing the immune system, etanercept increase the patient's susceptibility to infections. In rare cases, it may also cause serious conditions such as low blood count and heart problems.

<b>Adalimumab</b>

Adalimumab is another injectable prescription drug that works by blocking the action of TNF. Its side effects include headache, rashes, stomach upsets and skin irritation. Like other TNF-blocking drugs, adalimumab also suppresses the immune system and increases the risk of infection. It may also increase the risk of cancer. However, connection between adalimumab and the risk of cancer is yet to be conclusively established.

<b>Infliximab</b>

A prescription drug, infliximab also works by blocking TNF alpha. Common side effects of infliximab include cough, rashes, nausea, vomiting, headache, stomach pain, urinary or respiratory infections and allergic reactions. As with other TNF blockers, infliximab also increases the risk of infection. It may also lower the blood count, and in rare cases, cause liver and heart problems.

<b>Certolizmab Pegol</b>

Certolizumab pegol is another injectable prescription drug that blocks TNF and thereby reduces pain and inflammation. Side effects include sore throat, fever, cough and skin irritation at the injection site. It also increases the risk of infection and may cause or aggravate conditions such as tuberculosis, sepsis (blood infection), lowering of blood count, and heart conditions.

<b>Golimumab</b>

Golimumab is an injectable prescription drug which is a TNF blocker. As with other similar medication, its side effects include irritation at injection site, sore throat, respiratory tract infection and fever. It may also lower blood count and increase the risk of cancer.

<b>Anakinra</b>

Anakinra is a prescription drug. It works by blocking the effects of a protein called intereukin-1, a substance responsible for causing pain and inflammation. The side effects of anakinra are skin irritation at injection site, nausea, stomach upsets, and allergic reactions such as sore throat, cough or itching. Anakinra can also increase the risk of infection and cause serious conditions such as tuberculosis.

<b>Abacept</b>

Abatacept is an injectable prescription immunosuppressant. It works by blocking the action of a substance known as T-lymphocytes, which cause the symptoms of arthritis. The common side effects of this drug are dizziness, headache, nausea, rash, shortness of breath and allergic reactions such as swelling of the face, tongue, lips or throat. Serious side effects may include severe infections or even cancer.

<b>Rituximab</b>

Rituximab is a prescription drug that works by destroying B-cells, cells of the immune system that cause the symptoms of arthritis. Most common side effects include fever and chills that appear the first time the drug is administered but reduce over subsequent doses. Other side effects include nausea, headache, itching and a runny nose. Rituximab may also cause serious side effects such as low blood pressure, irregular heartbeat and heart attacks, as well as serious skin conditions that include Stevens-Johnson syndrome.

<b>Tocilizumab</b>

Tocilizumab is an injectable prescription drug that works by blocking a substance called interleukin-6 that causes pain and inflammation. Its side effects include headache, irritation at the injection site and stomach pain. It may also cause serious infection such as tuberculosis, blood infections, reduced blood count and severe allergic reactions.

<a>Glucorticoids [7] </a>

<b>Prednisolone</b>

Prednisolone is a prescription medicine that is very similar to glucocorticoid, a substance produced naturally by the human body. Much like glucocorticoids, prednisolone also acts to suppress the overactive immune system in arthritis patients, thereby reducing pain, swelling and inflammation. Side effects include headache, muscle weakness, fluid retention, weight gain and increased susceptibility to infection. Other serious side effects may include high blood pressure, peptic ulcer, aggravation of diabetes, glaucoma, cataract and psychological effects such as irritability, depression and mood swings.

<b>Prednisone</b>

This is another prescription drug [8] that suppresses the immune system of the body and reduces pain and inflammation. Side effects include the following:

<bl>

Muscle weakness

Fluid retention

Headaches

Glaucoma

Cataracts

Thinning

Easy bruising of the skin

Growth of facial hair

Euphoria

Depression

Mood swings

</bl>

<b>Cortisone Acetate</b>

Cortisone acetate is a prescription drug which is an immunosuppressant. Like other glucocorticoids, its side effects include weight gain, high blood pressure, low potassium, vision problems, headaches, nausea and mood changes.

<b>Betamethasone</b>

Betamethasone is a prescription only glucocorticoid which is available as a cream, ointment or lotion and is used to treat itching and inflammation on the skin. Side effects are burning, irritation, itching and dryness of the skin but these symptoms disappear as the body gets used to the medication.

<b>Dexamethasone</b>

Dexamethasone is a very potent glucocorticoid which is used as an immunosuppressant. Like other glucocorticoids, it is a prescription only drug and is used to treat a variety of diseases including cancer. Prolonged usage may cause serious side effects like cataract and bone thinning. Common side effects include the following:

<bl>

Increased appetite

Weight gain

Muscle weakness

Increased blood sugar

Insomnia

Irritability

Mood swings.

</bl>

<b>Hydrocortisone</b>

This is yet another prescription only glucocorticoid. Similarly to other glucocorticoids, hydrocortisone works by suppressing the immune system and exhibits similar side effects including weight gain, muscle weakness, glaucoma, cataract, high blood pressure and mood swings.

<b>Methylprednisolone</b>

Like other glucocorticoids, this is a prescription only immunosuppressive drug used to treat a variety of conditions. As with other drugs of this type, its side effects range from weight gain, fluid retention, vision problems and mood swings to serious conditions such as high blood pressure, glaucoma and peptic ulcers.

<a>Nonsteroidal Anti-inflammatory Drugs [9] </a>

<b>Aspirin</b>

Aspirin is an OTC drug used as an analgesic to relieve minor aches and pains associated with arthritis. It works by blocking the production of prostaglandins, substances that cause pain and fever. The most common side effects of aspirin are heartburn, stomach pains, nausea and vomiting. It some cases, it may cause allergic reactions such as hives and rashes.

<b>Choline and Magnesium Solicylates</b>

These are prescription drug which work by reducing the level of prostaglandins, chemicals that cause pain and inflammation. Common side effects are heartburn, nausea, vomiting, abdominal pains, stomach ulcers and hearing loss. In rare cases, they may also increase the risk of heart attack and strokes especially in people who already have high blood pressure or other heart conditions. It sometimes also causes bleeding from the stomach or the intestines.

<b>Diclofenac Potassium</b>

Diclofenac potassium is a prescription only drug although it is also available as OTC in some countries. It also works by reducing the levels of prostaglandins in the body through COX inhibition. Its side effects include nausea, heartburn, stomach upsets, chest pain, shortness of breath and slurred speech. It may also cause serious allergic reactions, high blood pressure, bleeding of the digestive tract, liver and heart problems.

<b>Diclofenac Sodium</b>

Diclofenac sodium is a prescription drug which is also available as OTC in some countries. It works by reducing the levels of prostaglandins. Side effects include heartburn, nausea, constipation, diarrhea, headache, dizziness and drowsiness. It may also cause ulcers in the stomach and intestines as well as cardiovascular conditions such as heart attacks.

<b>Naproxen</b>

Naproxen works as a COX inhibitor, thereby reducing the levels of prostaglandins in the body. It is a prescription drug in most countries although it is also available as an OTC drug in the US. Similar to other NSAIDs, the most common side effects of naproxen include nausea, heartburn, constipation or diarrhea, stomach pain and shortness of breath. It may also cause serious side effects such as stomach ulcers and intestinal bleeding, heart problems and liver damage.

<b>Naproxen Sodium</b>

Naproxen sodium is an analgesic drug available as OTC. Similar to other NSAIDs, it is a COX inhibitor and reduces the levels of prostaglandins which cause inflammation. Its side effects are the same as other NSAIDs and include heartburn, constipation, nausea, stomach pain, dizziness, cardiovascular problems and liver damage.

<b>Sodium Salicylate</b>

Sodium salicylate is an NSAID, available as an OTC medication. It is usually prescribed as an alternative to patients who are allergic of aspirin. Its side effects are similar to those of other NSAIDs and include nausea, vomiting, gastric irritation, ulceration and gastrointestinal bleeding.

<b>Magnesium Salicylate</b>

Magnesium salicylate is available as an OTC and works by reducing the substances in the body which cause inflammation. Its side effects are similar to other NSAIDs and include stomach upsets, nausea, heartburn, weight gain and hearing changes. Like other NSAIDs, it might cause bleeding from the stomach and intestines. It also increases the risk of heart attacks.

<b>Diflunisal</b>

Diflunisal is a prescription drug and like some other NSAIDs, it acts by reducing the production of prostaglandins. Its side effects are also similar to those of other NSAIDs and include problems of the gastrointestinal system including nausea, gas, stomach upsets as well as ulcers, gastrointestinal bleeding and liver problems.

<b>Etodolac</b>

Etodolac is another prescription NSAID that lowers the levels of prostaglandins in the body, thereby reducing the pain and inflammation. It exhibits the common side effects associated with other NSAIDs including constipation, diarrhea, vomiting, headaches, ringing in the ears, and serious conditions such as heart, kidney and liver problems.

<b>Fenoprofen Calcium</b>

Fenoprofen calcium is a prescription drug, and like other NSAIDs it also works by reducing the production of prostaglandins in the body. The side effects of this drug are similar to those of other NSAIDs and include nausea, vomiting, indigestion, dizziness, drowsiness and headaches. Serious side effects include heart problems, gastrointestinal bleeding and impairment of kidney functions.

<b>Flurbiprofen</b>

Another prescription NSAID, flurbiprofen works as a COX inhibitor and is used to treat pain and inflammation. Its side effects range from headache, nausea, stomach upset, dizziness and insomnia to serious conditions such as cardiovascular problems, vision problems, gastrointestinal bleeding, kidney and liver problems.

<b>Ibuprofen</b>

Ibuprofen is available both as an OTC and a prescription drug and works by suppression of prostaglandins. The most common side effects of ibuprofen are stomach pain, nausea and heartburn. Like other NSAIDs, it may cause more serious side effects such as gastrointestinal bleeding, liver and kidney problems and cardiovascular problems including heart attacks and strokes.

<b>Indomethacin</b>

Indomethacin is a prescription NSAID that works as a COX inhibitor and reduces the production of prostaglandins in the body. Its side effects include indigestion, dizziness, nausea and vomiting, as well as serious conditions such as gastrointestinal bleeding, liver or kidney problems and cardiovascular problems including heart attacks and strokes.

<b>Ketoprofen</b>

Ketoprofen is a prescription drug that reduces the production of prostaglandins in the body. Its side effects are similar to those of other NSAIDs and include nausea, stomach pain, vomiting, diarrhea and other serious conditions such as peptic ulcer, gastrointestinal bleeding, kidney and liver problems as well as heart attacks and strokes.

<b>Mobidin</b>

Mobidin is an OTC drug used to treat mild to moderate joint pains related to arthritis. Like other NSAIDs, mobidin works by blocking chemicals in the body that cause pain and inflammation. Its side effects include liver and kidney problems, gastrointestinal bleeding and cardiovascular problems, in addition to milder conditions such as nausea, heartburn, stomach upsets and dizziness.

<b>Mecofenamate Sodium</b>

This is an OTC drug that works by reducing the levels of prostaglandins in the body. Its side effects include gastrointestinal problems such as nausea, vomiting, diarrhea, gas and heartburn. Serious side effects include gastrointestinal bleeding, liver damage and cardiovascular problems.

<b>Mefenamic Acid</b>

Mefenamic acid is a prescription drug that works by reducing the levels of prostaglandins in the body. Common side effects include nausea, heartburn, stomach upsets, dizziness, drowsiness and headaches. Serious side effects range from high blood pressure, heart attacks and strokes to liver problems and gastrointestinal bleeding.

<b>Meloxicam</b>

Meloxicam is yet another prescription NSAID that reduces prostaglandins in the body. As with other NSAIDs, its common side effects are related to the gastrointestinal tract and include nausea, vomiting, diarrhea and abdominal pain. Serious side effects include ulcers, gastrointestinal bleeding, kidney problems, liver damage and heart attacks and strokes.

<b>Nabumetone</b>

Nabumetone is a prescription drug that provides relief from pain and inflammation by reducing the levels of prostaglandins in the body. Common side effects of nabumetone include nausea, constipation and abdominal pain. Serious side effects include gastrointestinal bleeding, kidney impairment and liver problems.

</b>Oxaprozin</b>

Oxaprozin is a prescription drug, and like other NSAIDs, it works by reducing the levels of prostaglandins in the body. Its side effects are similar to those of other NSAIDs and range from nausea, abdominal pain, diarrhea and headaches to more serious conditions including gastrointestinal bleeding, cardiovascular problems, kidney impairment and liver damage.

<b>Piroxicam</b>

Piroxicam is a prescription drug and works by reducing prostaglandins. The most common side effects of piroxicam are nausea, constipation, abdominal pain, dizziness and drowsiness, while the more serious side effects include gastrointestinal bleeding, kidney impairment and heart attacks.

<b>Rofecoxib</b>

Rofecoxib is a prescription NSAID that has been voluntarily withdrawn from the market after studies indicated that it caused an increased risk of serious cardiovascular problems that include heart attacks and strokes.

<b>Salsalate</b>

This is a prescription drug known to block the production of prostaglandin in the body. Like other NSAIDs, the side effects range from nausea, abdominal pain, diarrhea and gastritis to more serious conditions such as gastrointestinal bleeding, cardiovascular problems, kidney impairment and liver damage.

<b>Sulindac</b>

Sulindac is another prescription drug that works by reducing the level of prostaglandin in the body. Side effects of sulindac range from diarrhea, abdominal pain and heartburn to ulcers and gastrointestinal bleeding, heart attacks and strokes, kidney problems and liver damage.

<b>Tolmetin Sodium</b>

Tolmetin sodium is a prescription drug which, like other NSAIDs, works by blocking the chemicals in the body that cause pain and inflammation. Side effects include the problems of the digestive tract and serious conditions such as heart attack, stroke and stomach ulcers.

<b>Valdecoxib</b>

Valdecoxib [10] is a COX inhibiting NSAID which has been withdrawn from the market due to a high risk of heart attacks, strokes, and serious (sometimes fatal) skin reactions.

<a>Staying on the Defensive</a>

<b> Taking Side Effects of Pharmacological Drugs Seriously</b>

All medicines, whether prescription or OTC, have side effects that may range from mild problems to serious, sometimes fatal conditions. While all drugs are thoroughly tested for possible side effects before getting marketed, it is difficult to predict the side effects that may arise due to long term usage. Further, side effects may vary from patient to patient and may affect different parts of the body. Seemingly mild side effects may sometimes be indicative of some major complication. Therefore, it is always important to be aware of all possible risks associated with the medication being prescribed. It also equally advisable to discuss these with the doctor to make sure that any adverse effects are monitored and appropriate corrective actions are taken.

<b>Prescription Adherence</b>

In case of long term health problems such as arthritis, it is important to follow the prescription and take the medication strictly as directed by the doctor. This is known as prescription or medication adherence. Lack of prescription adherence results in the disease not being treated properly leading to further complications. Taking medication irregularly or in the wrong dosage may also lead to other health serious conditions like kidney impairment, liver damage or cardiovascular problems, which may be fatal. [11] 

Prescription adherence really ensures that the arthritis patient is getting the treatment he or she requires and that the side effects are under control. Arthritis is a progressive condition, and prescription adherence will (1) reduce the pain and other symptoms, (2) prevent further joint damage, and (3) reduce the dangers of side effects and arrest the progression of the disorder, enabling the patient to lead an active and independent life.

<a>Analysis</a>

While most of the pharmacological approaches used for the treatment of arthritis have a range of side effects from mild to severe, it must be remembered that most arthritis patients tolerate these drugs quite well and do not suffer from any major side effects. In case of any concerns regarding the side effects, the arthritis victim should discuss these openly with a physician and be aware of both the risks and the benefits of using a particular drug. The patient should also adhere to the prescription and take the medication in the correct dose and timing. If this is done, the side effects can be controlled and minimized and the patient can get full benefits from the prescribed medication.

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