How to take treatment ?

Methotrexate comes either as pills or as a subcutaneous injection. Methotrexate is usually taken as a single dose once per week to improve absorption or avoid side effects; occasionally the dose is split into two doses. Your doctor also may prescribe a folic acid (or folate) vitamin supplement to decrease the chance of side effects. Methotrexate should not be taken if kidney or liver function is not normal. Alcohol significantly increases the risk for liver damage while taking methotrexate, so alcohol should be avoided. Regular laboratory monitoring is required to monitor blood counts and your liver while taking methotrexate. Improvements in arthritis and other conditions usually are first seen in 3-6 weeks. The full benefit of this drug may not be seen until after 12 weeks of treatment.

What are the possible risks and side effects?

You should contact your doctor if you develop symptoms of an infection, such as a fever or cough,or if you think you are having any side effects. If you develop symptoms of an infection while using this medication, you should stop it and contact your doctor. The most common side effects are gastrointestinal upseand elevations of liver function tests. About 1-3% of patients develop mouth sores (called stomatitis), rash, diarrhea, and abnormalities in blood counts. Some side effects do not cause symptoms, so it is important to have routine blood tests performed every 8-12 weeks. Methotrexate may cause cirrhosis (scarring) of the liver,but this side effect is rare and most likely to occur in patients who already have liver problems or are using alcohol or taking other drugs that are toxic to the liver. Lung problems (persistent cough or unexplained shortness of breath) can occur rarely when taking methotrexate. Slow hair loss is seen in some patients, but hair grows back when the person stops taking this medication. This can often be managed by taking folic acid. It is important to remember that most patients do not experience side effects, and that, for those who do, many of the minor side effects will improve with time.

What precautions are necessary?

Blood tests: As methotrexate may affect the liver and blood cells, you must have regular blood tests during methotrexate,your treatment. This is very important, as you may not get symptoms with some of these

How to take treatment ?

It’s given as a capsule or as a tablet depending on the dose required, and is usually taken twice a day with food or water. They should be swallowed whole and not crushed or chewed.

Your doctor will advise you about the correct dose. Higher doses are usually taken as tablets rather than capsules.

What are the possible risks and side effects?

The most common side-effects of mycophenolate are nausea (feeling sick), diarrhoea, vomiting or stomach pain. Mycophenolate can also affect your blood count (one of the effects is that fewer blood cells are made) and can make you more likely to develop infections.

You should tell your doctor or rheumatology nurse specialist straight away if you develop any of the following after starting mycophenolate:

  • a sore throat
  • a fever
  • any other symptoms of infection
  • unexplained bruising or bleeding
  • any other new symptoms or anything else that concerns you.

How to take treatment?

Sulfasalazine comes in a 500mg tablet and should be taken with food and a full glass of water to avoid an upset stomach. The medication is often started at low doses when treating RA to prevent side effects, typically 1 to 2 tablets a day. After the first week, the dose may be slowly increased to the usual dosage of 2 tablets (1g) twice a day. This dose can be increased to up to 6 pills (3g) a day in some situations. An Enteric-coated (or stomach-coated) preparation is available that may lessen some of the side effects associated with sulfasalazine, particularly stomach upset. This form of sulfasalazine should not be crushed or chewed. Adequate fluid intake is required to prevent kidney stones. It usually takes between 2 to 3 months to notice any improvement in RA symptoms after starting sulfasalazine.

What are the risks and side effects ?

In general, most patients can take sulfasalazine with few side effects. The most common side effects are nausea and abdominal discomfort, which occurs early in the course of treatment. Serious side effects, such as stomach ulcers, are actually less common with sulfasalazine than with non-steroidal anti-inflammatory drugs (NSAIDs such as ibuprofen). Abdominal side effectsthat do occur with sulfasalazine usually improve with time,and are often avoided by slowly increasing from a low starting dose. Sun sensitivity of the skin can also be a a side effect. Those on sulfasalazine should use sunscreen (SPF 15 or higher) when outdoors and avoid prolonged exposure to sunlight. Some people will develop orange colored urine and even orange skin. This should not cause alarm. It is usually harmless and goes away after medication is stopped. In some cases, sulfasalazine may reduce the number of disease-fighting white blood cells in the body. This often does not cause symptoms, but can be detected by regular blood tests performed by your doctor. Sulfasalazine also increases the risk of reduced blood counts in people born with deficiency of an enzyme called Glucose-6 phosphate dehydrogenase. Most rashes are not serious, but occasionally patients taking sulfasalazine develop a more severe rash and should be evaluated by their doctor to determine if the medication should be discontinued.

What precautions are necessary?

Blood tests

  • Since sulfasalazine may affect the blood cells and liver, you must have regular blood tests during your treatment. This is important, as you may not get symptoms with these problems.
  • Blood tests are particularly important during the first few months of treatment and when sulfasalazine is taken with methotrexate and/or leflunomide.

Precautions with other diseases orconditions

  • You should not take sulfasalazine if you have sensitivity to aspirin compounds or sulphur containing medicines such as sulphur antibiotics (e.g. Bactrim or Septrim).
  • If you have blood, kidney or liver disorders your doctor will discuss your medical history to decide whether this treatment is suitable for you.

Use with other medicines

  • Sulfasalazine can interact with other medicines. You should tell your doctor (including your general practitioner, rheumatologist and others) about all medicines you are taking or plan to take. This includes over the counter or herbal/naturopathic medicines. You should also mention your treatment to other health professionals.

How to take treatment ?

It may take several weeks after starting leflunomide to experience an improvement in joint pain or swelling. Complete benefits may not be experienced until 6-12 weeks after starting the medication.

What are the possible risks and side effects?

The most common side effect of leflunomide is diarrhea, which occurs in approximately 20 percent of patients. This symptom frequently improves with time or by taking a medication to prevent diarrhea. If diarrhea persists, the dose of leflunomide may need to be reduced. Less common side effects include nausea, stomach pain, indigestion, rash, and hair loss. In fewer than 10 percent of patients, leflunomide can cause abnormal liver function tests or decreased blood cell or platelet counts. Rarely, this drug may cause lung problems, such as cough, shortness of breath or lung injury.

How to take treatment ?

Hydroxychloroquine is taken by mouth in tabletform. The usual dose is one tablet (200mg) once or twice a day. Tablets can be taken altogether, once a day.

The dose may be reduced to a maintenance dose after a few months once a response is achieved. Occasionally it may be taken every second day.

It is best taken with food as it has a slightly bitter taste.

Hydroxychloroquine is not a pain killer and it should be taken continuously to be effective. Other medicines may be required to treat the pain.

Hydroxychloroquine may be used with other arthritis medicines including:

  • other DMARDs such as methotrexate
  • steroid medicines such as prednisolone or cortisone injections into the joint
  • anti-inflammatory medicines (NSAIDs) such as naproxen (Naprosyn) and ibuprofen (Brufen, Nurofen)
  • simple pain medicines such as paracetamol.

What are the possible risks and side effects?

You might experience side effects with your treatment. Tell your doctor if you are concerned about possible side effects. A reduction in dose may minimise side effects so that you can continue to take this treatment. Your doctor will advise on any dose changes that are necessary.

Most common possible side effects

  • About 10% of patients experience stomach and bowel side effects such as nausea (feeling sick), loss of appetite or diarrhoea. As the tablets are slightly bitter, these problems can often be reduced by taking the tablets with food or milk, or they may just improve with time.

Less common or rare possible side effects

  • Less common side effects include skin rashes and increased sensitivity to the sun. It is a good idea to wear sunscreen and a hat when in the sun. The medication may rarely worsen psoriasis rash.
  • Very rarely hydroxychloroquine may cause temporary blurring of vision due to deposits in the front of the eye (cornea). This is fully reversible when the medicine is stopped. You should report to your doctor any visual disturbances, (blurred vision, mist or fog before the eyes or light sensitivity).
  • More serious eye problems involving the retina (back of the eye) are extremely rare. These occur mainly in people taking a high dose for longer than 5 years, or in those who have liver or kidney problems. Your doctor will advise you about what eye testing is required.
  • Very rare effects include thinning of the hair, ringing in the ears, bleaching of the skin and/or hair, and weakness of the leg muscles.

What precautions are necessary?

Eye testing

  • When you start treatment with hydroxychloroquine your doctor will discuss your vision and may ask you to have an eye test. This eye test may be repeated during your treatment to monitor effects on your eyesight.

Use with other medicines

  • Hydroxychloroquine can interact with other medicines. You should tell your doctor about all the medicines you are taking or plan to take. This includes over the counter or herbal/naturopathic medicines. You should also mention your treatment when you see other health professionals.
  • Most vaccines can be given safely. Talk with your doctor before receiving any vaccines.

Use with alcohol

  • There is no particular reason for you to avoid alcohol while taking hydroxychloroquine. However drinking more than 4 standard drinks on one occasion, even if infrequently, is strongly discouraged.

Use in pregnancy and breastfeeding

  • If you intend becoming pregnant, or if you conceive while taking hydroxychloroquine, or if you are breastfeeding, you should discuss this with your doctor.
  • Hydroxychloroquine can be used in pregnancy if the mother’s condition is serious however you should ask your doctor about the benefits and risks of taking
    hydroxychloroquine while you are pregnant.

How to take treatment ?

Azathioprine is usually given as tablets, taken once or twice daily. It’s usually taken with or after food.

What are the possible risks and side effects?

As with all medications, azathioprine can sometimes cause side-effects. Azathioprine may cause nausea (feeling sick), vomiting, diarrhoea, loss of appetite (which may be alleviated by taking with food or last thing at night), hair loss and skin rashes. Minor side-effects can sometimes be helped by reducing the dose – speak to your doctor about this.

You should tell your doctor or nurse specialist straight away if you develop any of the following after starting azathioprine:

  • a sore throat, fever or any other signs of infection
  • unexplained bruising or bleeding
  • yellowing of the skin or eyes (jaundice)

What precautions are necessary?

Azathioprine can affect the function of the liver or bone marrow. All patients taking azathioprine require regular blood tests to check on this.

There is a way of predicting severe bone marrow problems with a blood test. This is usually checked in everyone before starting azathioprine. Those few people at high risk will not be given the drug.

See your doctor urgently if you develop unexplained bruising, severe sore throat or fever as these can be an early sign of bone marrow suppression, but these are very unlikely to happen if you are having regular blood tests.

How to take treatment ?

Like penicillin, ciclosporin is a substance produced by a fungus. Ciclosporin was found to suppress the immune system and was initially developed for suppressing the immune system of transplant patients to prevent them rejecting their transplanted kidneys and other organs. It was subsequently found to benefit patients with a wide range of diseases caused by immune reactions.

What are the possible risks and side effects?

The long-term (over several months or years) side effects of ciclosporin include reduced function of the kidneys and raised blood pressure. Kidney function can be measured using a blood test. The dose of ciclosporin has to be reduced or stopped if there is a rise in blood pressure or effects on the kidneys. Provided the treatment is monitored and appropriate adjustments are made, these side effects are largely reversible. Ciclosporin can also cause increased levels of lipids (for example cholesterol) in the blood.

The functions of the immune system include protection from infections and cancers. Taking ciclosporin may therefore reduce your resistance to serious infections (e.g. tuberculosis or hepatitis). Minor infections, such as colds, are probably not increased. If you have not had chicken pox, and you come into contact with someone who has chicken pox or shingles (which is also caused by the chicken pox virus), you should inform your doctor promptly as it may be necessary for you to be given treatment to protect you.

In transplant patients who have taken ciclosporin with other drugs which also suppress the immune system there is an increased risk of many types of cancer. If you develop a cancer while taking ciclosporin this might grow faster as a result of the immunosuppression. This includes skin cancer, so patients on ciclosporin should avoid exposing their skin to the sun, and apply a sunscreen to exposed skin when out of doors, especially in the summer. Skin cancer is a risk in patients who have received a lot of treatment with ultraviolet light, particularly those with psoriasis or who have exposed their skin to a lot of sun over the years.You should talk to your doctor about this if you have any concerns, if you find any new growths on your skin, or if any mole or area of skin changes colour or texture.

What precautions are necessary?

As ciclosporin can affect the kidneys and blood pressure, your doctor will arrange for you to have regular tests of your blood, and checks on your blood pressure. These tests will be carried out frequently at first and less often once the dose is stable. You may be asked to keep a record booklet with your test results. Take this with you when you visit your General Practitioner or go to hospital.

You must not take ciclosporin unless you are having regular checks.

How to take treatment ?

Cyclosporin is taken in tablet form it should be swallowed whole with water. Although it is usually taken in capsule form it can be given as an IV injection if you are admitted to hospital during a ‘Flare-up’ and unable to take it by mouth.

What are the possible risks and side effects?

All medications can cause side effects in some people. It is a question of balancing the risk of side effects against the benefits of treatment. Some of the side effects of Cyclosporin are: –

  • Sickness and loss of appetite. This normally settles as you get use to taking the tablets.
  • Blood problems, this is why you have regular blood tests that pick up any problems before they cause you symptoms. If whilst taking Cyclosporin you develop flu like symptoms, a fever, a severe sore throat or mouth or other symptoms of an infection STOP the tablets immediately contact your GP or Consultant. You will then need a blood test to check your White Blood Cell count is OK
  • Kidney problems which can affect how your kidneys work and cause a rise in blood pressure
  • Burning sensation tremor and pins and needles can occur in hands and feet during the first week of treatment but this usually disappears
  • Increase in bodily and facial hair
  • Overgrowth and bleeding from the gums although this usually occurs in patients who have been taking cyclosporin for a long time. It is important to maintain good dental hygiene.

What are bisphosphonates?

Bisphosphonates are medicines used to treat bone diseases such as osteoporosis and Paget’s disease. Alendronate and risedronate are the most commonly prescribed bisphosphonate tablets in Australia.

Osteoporosis is a common disease, which causes bones to become fragile and brittle so that they break (fracture) more easily, even as a result of normal activity (as distinct from a fall).

Fractures may be painful and restrict a person’s ability to carry out their normal daily tasks.

In osteoporosis, bisphosphonates reduce the risk of a broken bone or fracture. In Paget’s disease, the formation of abnormal bone causes deformity and pain. Bisphosphonate medicines can help this.

How do they work?

Bone is constantly changing with old bone breaking down and new bone is formed to take its place. This usually happens in a balanced way. If the cycle becomes unbalanced, bone is broken down faster than it is replaced. This leads to osteoporosis.

Bisphosphonates slow or stop the bone breaking down. As a result, bone density may increase over time so the risk of fractures is reduced.

What benefit can you expect from your treatment?

Since osteoporosis doesn’t usually have any symptoms such as pain (until a fracture occurs) you will not ‘feel’ any immediate benefit from your treatment with bisphosphonates.

If used for Paget’s disease, bone pain may lessen with time. Your doctor will explain the likely benefits relevant to you.

You may be asked to have tests to check the effect of treatment on your bones. For example, a bone mineral density test is usually done after one to two years of treatment. This is a type of x-ray, which involves a very small amount of radiation.

Tests of urine or blood are sometimes used to measure the effects of treatment on bone formation and breakdown.

How are bisphosphonates taken?

Bisphosphonates come as tablets, but can also be given by injection

It is important to follow the directions carefully to avoid side effects and to make sure the tablets work properly. See Important things to remember on the first page of this sheet, and ask your doctor about the instructions relevant to the medicine you have been prescribed.

What is the dosage?

Tablets come in different strengths. The dose will depend on the type of bisphosphonate being taken and the condition for which it is being used.

For osteoporosis, the medicines are taken as a single tablet once a week or once a month for a number of years.

For Paget’s disease, they are usually taken daily for a limited period. Always follow the instructions provided in the packaging unless otherwise directed by a doctor.

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