Medication Summary
The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Agents used to treat patients with viral arthritis include the following:
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Nonsteroidal anti-inflammatory drugs (NSAIDs)
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Antimalarials
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Immunoglobulins
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Interferons
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Corticosteroids
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Antineoplastic agents
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Other anti-inflammatory drugs
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Analgesics
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Antivirals
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Antibiotics
Nonsteroidal Anti-inflammatory Drugs
Class Summary
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. Their mechanisms of action are unknown, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may be present, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
Naproxen (Anaprox, Naprelan, Aleve, Naprosyn)
Naproxen is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which is responsible for prostaglandin synthesis.
Ibuprofen (Motrin, Advil, Adapin, Caldolor)
Ibuprofen is the drug of choice for mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. Many doses are available, either with or without a prescription.
Ketoprofen
Ketoprofen is used for the relief of mild to moderate pain and inflammation. Small doses are indicated initially in patients with small body size, elderly patients, and persons with renal or liver disease. Doses of over 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe the patient for response.
Flurbiprofen
Flurbiprofen may inhibit cyclooxygenase, thereby inhibiting prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
Diclofenac (Voltaren XR, Cataflam, Cambia)
This is one of a series of phenylacetic acids that has demonstrated anti-inflammatory and analgesic properties in pharmacological studies. It is believed to inhibit the enzyme cyclooxygenase, which is essential in the biosynthesis of prostaglandins. Diclofenac can cause hepatotoxicity; hence, liver enzymes should be monitored in the first 8 weeks of treatment. It is absorbed rapidly; metabolism occurs in the liver by demethylation, deacetylation, and glucuronide conjugation. The delayed-release, enteric-coated form is diclofenac sodium, and the immediate-release form is diclofenac potassium.
Tolmetin
Tolmetin inhibits prostaglandin synthesis by decreasing the activity of the enzyme cyclooxygenase, which, in turn, decreases the formation of prostaglandin precursors. The pediatric dosage is 20 mg/kg/d PO divided tid/qid initially, then 15-30 mg/kg/d, not to exceed 30 mg/kg/d.
Celecoxib (Celebrex)
Celecoxib inhibits primarily COX-2. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, the incidence of GI toxicity, such as endoscopic peptic ulcers, bleeding ulcers, perforations, and obstructions may be decreased when compared with nonselective NSAIDs.
Seek the lowest dose for each patient. The adult dosage is 100-200 mg PO bid; the pediatric dosage has not been established for patients younger than 2 years, is 50 mg PO bid for patients 2 years or older whose weight ranges from 10 kg to no heavier than 25 kg, and is 100 mg PO bid for patients 2 years or older who weigh more than 25 kg.
Indomethacin (Indocin)
Indomethacin is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis.
Antimalarial agents
Class Summary
Antimalarial agents are derivatives of 4-aminoquinoline and are active against various autoimmune disorders.
Hydroxychloroquine (Plaquenil)
Hydroxychloroquine inhibits chemotaxis of eosinophils and locomotion of neutrophils and impairs complement-dependent antigen-antibody reactions. Hydroxychloroquine sulfate 200 mg is equivalent to 155 mg hydroxychloroquine base and 250 mg chloroquine phosphate.
Immunoglobulin agents
Class Summary
Immunoglobulins are used to improve clinical and immunologic aspects of the disease. They may decrease autoantibody production and increase solubilization and removal of immune complexes.
Immune globulin, intravenous (Carimune NF, Gammaplex, Octagam, Gammagard)
Neutralizes circulating myelin antibodies through antiidiotypic antibodies; down-regulates proinflammatory cytokines, including INF-gamma; blocks Fc receptors on macrophages; suppresses inducer T and B cells and augments suppressor T cells; blocks complement cascade; promotes remyelination; may increase CSF IgG (10%).Immune globulin, intravenous (Carimune NF, Gammaplex, Octagam, Gammagard)
Intravenous immune globulin (IVIg) neutralizes circulating myelin antibodies through anti-idiotypic antibodies; down-regulates proinflammatory cytokines, including interferon gamma; blocks Fc receptors on macrophages; suppresses inducer T and B cells while augmenting suppressor T cells; blocks the complement cascade; promotes remyelination; and may increase immunoglobulin G (IgG) in cerebrospinal fluid (CSF) (10%).
Immunomodulators
Class Summary
Interferons are naturally produced proteins with antiviral, antitumoral, and immunomodulatory actions. Interferons alfa, beta, and gamma may be given topically, systemically, and intralesionally.
Interferon alfa-2b (Intron A)
Interferon alfa-2b is a protein product manufactured by means of recombinant DNA technology. The mechanism of its antitumor activity is not clearly understood; however, direct antiproliferative effects against malignant cells and modulation of host immune response may play important roles.
Corticosteroids
Class Summary
Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body’s immune response to diverse stimuli.
Prednisone
Prednisone is an immunosuppressant used for treatment of autoimmune disorders; it may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear leukocyte (PMN) activity. Prednisone stabilizes lysosomal membranes and suppresses lymphocyte and antibody production.
Prednisolone (Millipred, Orapred, Orapred ODT, Prelone)
Corticosteroids act as potent inhibitors of inflammation. They may cause profound and varied metabolic effects, particularly in relation to salt, water, and glucose tolerance, in addition to their modification of the immune response of the body. Alternative corticosteroids may be used in equivalent dosage.
Antineoplastic Agents
Class Summary
These agents inhibit key factors responsible for deregulated cell proliferation.
Cyclophosphamide
Cyclophosphamide is an alkylating agent that depresses T- and B-cell function.
Methotrexate (Folex PFS, Rheumatrex)
Unknown mechanism of action in treatment of inflammatory reactions; may affect immune function. Ameliorates symptoms of inflammation (eg, pain, swelling, stiffness). Adjust dose gradually to attain satisfactory response.
5-Aminosalicylic Acid Derivatives
Class Summary
Anti-inflammatory agents inhibit key factors responsible for inflammation.
Sulfasalazine (Azulfidine, EN-tabs)
Sulfasalazine is useful in the management of ulcerative colitis and acts locally in the colon to decrease the inflammatory response. It systemically inhibits prostaglandin synthesis.
Analgesics
Class Summary
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who experience pain.
Acetaminophen (Aspirin-Free Anacin, FeverAll, Rapimed Junior, Tylenol)
Acetaminophen is the drug of choice for managing pain in patients who have documented hypersensitivity to aspirin or NSAIDs, who have upper gastrointestinal (GI) disease, or who are taking oral anticoagulants.
Antiviral agents
Class Summary
Nucleoside analogues are initially phosphorylated by viral thymidine kinase (TK) and eventually form a nucleoside triphosphate. These molecules inhibit herpes simplex virus (HSV) polymerase with 30-50 times the potency with which they inhibit human alpha-DNA polymerase.
Ribavirin (Rebetol, Virazole, Copegus)
Ribavirin is indicated for chronic hepatitis C virus (HCV) infection. It inhibits replication of RNA and DNA viruses; in addition, it inhibits initiation and elongation of RNA fragments, resulting in inhibition of viral protein synthesis.
Antibiotics
Class Summary
Antibiotic therapy must cover all likely pathogens in the context of this clinical setting. Indications include Pneumocystis jiroveci pneumonia and HCV infection.
Pentamidine (Pentam-300, NebuPent)
Pentamidine inhibits the growth of protozoa by blocking oxidative phosphorylation and inhibiting incorporation of nucleic acids into RNA and DNA, causing inhibition of protein and phospholipid synthesis.
Trimethoprim-sulfamethoxazole (Septra DS, Bactrim, Bactrim DS)
Trimethoprim-sulfamethoxazole (TMP-SMZ) inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. The antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except for Pseudomonas aeruginosa.
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Viral arthritis. Typical "slapped cheek" appearance. Courtesy of Brenda Moroz, MD, Montreal Children's Hospital.
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Viral arthritis. "Slapped cheeks" with typical reticulated erythema of arms. Courtesy of Brenda Moroz, MD, Montreal Children's Hospital.
