PH2.8 | PH2.8 | Case-Based Anti-Inflammatory Therapeutics — SDL Guide — Summary & Reflection

KEY TAKEAWAYS

Key takeaways from this module:

Gout:
1. Acute attack: NSAID (indomethacin or naproxen) OR low-dose colchicine (1 mg then 0.5 mg) OR corticosteroids (if NSAIDs/colchicine contraindicated — e.g., severe CKD).
2. Never start allopurinol during an acute attack — wait until fully resolved (2–4 weeks), then titrate to UA target <6 mg/dL.
3. Co-prescribe colchicine prophylaxis for first 3–6 months of ULT; consider switching thiazide diuretic to losartan.
4. Aspirin at low doses RAISES uric acid — do not use as the NSAID of choice in gout.

Arthritis:
5. OA: stepwise symptom management (paracetamol → NSAIDs + PPI → intra-articular); NO DMARDs.
6. RA: DMARDs are obligatory and must be started early. Methotrexate is the anchor; co-prescribe folic acid. NSAIDs provide symptomatic relief only; they do not modify disease. MTX + NSAIDs = monitor for MTX toxicity.

Migraine:
7. Mild attacks: paracetamol + metoclopramide or ibuprofen. Moderate-severe: triptans (selective 5-HT1B/1D agonists — sumatriptan, rizatriptan) — contraindicated in CVD.
8. Prophylaxis (≥4 attacks/month): propranolol or topiramate first-line; amitriptyline second-line; valproate effective but strictly avoided in women of childbearing potential (teratogenic).
9. Analgesic overuse (>10–15 days/month) → medication overuse headache — a preventable complication.

REFLECT

Return to the three patients. Patient A (gout) needs indomethacin or colchicine now and allopurinol later — the two-phase plan, sequenced correctly. Patient B (RA) needs methotrexate plus a DMARD combination — NSAIDs alone are failing her joints even if they relieve her pain. Patient C (migraine) needs sumatriptan for acute attacks and propranolol for prophylaxis — paracetamol was never going to be enough for a moderate-severe migraine.

The skill you are practising here is not memorising drug names but clinical reasoning under the constraints of each patient's biology, co-morbidities, and risk profile. A 52-year-old man with CKD and gout gets a different management plan from a 30-year-old man with normal renal function and gout. A 28-year-old woman with migraine gets a different prophylactic drug from a 65-year-old man with the same condition. Drug knowledge is the raw material; clinical reasoning is the craft.